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Science of Migraine

Living in areas where fracking takes place doubles the risk of having migraines, as well as fatigue and sinus symptoms. Fracking, or hydraulic fracturing, is a water-based method of extracting natural gas from deep under the ground.

Johns Hopkins researchers described these findings in the journal Environmental Health Perspectives. The study was conducted using questionnaires which were completed by 7,785 adults. Among these people, 1,765, or 23% suffered from migraines, 1,930 people or 25% experienced severe fatigue and 1,850 or 24% had symptoms of chronic sinusitis (three or more months of nasal and sinus symptoms). In the general population the incidence of migraines is about 12%.

Previous studies have discovered an association between fracking and increased risk of premature births, asthma attacks and indoor radon concentrations.

It is unclear how fracking results in these health problems. Some possible explanations include air pollution, odors, noise, bright lights, and heavy truck traffic.

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Menopause often brings relief to female migraine sufferers. However, many women have worsening of their migraines during the transition. This is thought to be due to the fluctuating levels of estrogen, which is also responsible for menstrual migraines. Steady levels of estrogen during pregnancy and in menopause lead to a dramatic relief of migraines in two out of three women.

A study published in a recent issue of the journal Headache examined the relationship of headache frequency to the stages of menopause. The study looked at 3446 women with migraines with a mean age of 46. Among women who were premenopausal, 8% had high frequency of headaches (10 or more headache days each month), while during perimenopause as well as menopause, 12% of women had high frequency of migraines. This does not contradict the fact that many women stop having migraines in menopause, but it suggests that among those women who continue having migraines, there are more with high frequency of attacks.

By publishing these findings, the authors wanted to draw attention to the fact that many women may need a more aggressive approach to treatment. In women with high frequency of attacks preventive therapies tend to be more effective than abortive ones. These may include magnesium, CoQ10, Boswellia, and other supplements, as well as preventive medications and Botox injections. At the same time, most women may also need to take abortive therapies, such as triptans.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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23andMe offers direct-to-consumer genetic testing by analyzing a saliva sample. It provides information on predisposition for more than 90 traits and conditions ranging from acne to Alzheimer’s. Health-related results were suspended by the FDA because of the concern was that consumers may not be able to correctly interpret the health data, particularly regarding conditions such as Alzheimer’s Parkinson’s, various cancers, and other. What is available is genealogical data and information on several conditions which did receive FDA approval. As of June 2015, 23andMe has genotyped over 1,000,000 individuals.

After submitting a saliva sample, consumers are asked to complete a number of surveys about their medical conditions, including migraines, personal habits, and other information. This has led to some important discoveries, which have been published in scientific journals. Here are some results related to migraines.

23andme discovered three genes which make migraines more likely. This discovery is not as important as it seems because these genes increase the risk of migraines by a very small amount and because dozens of other migraine susceptibility genes are being continuously identified.

In 2012 23andme acquired CureTogether, a “health research project that brings patients and researchers together to find cures for chronic conditions”, where some of the following information comes from.

Here is interesting, but also not very surprising information on most commonly reported migraine triggers:

stress (85%)
insufficient sleep (72%)
dehydration (64%)
looking at bright sunlight (61%)
inhaling smoke/strong odors (57%)
staring at a computer screen (56%)
flashing or flickering lights (56%)
weather changes (50%)
low blood sugar (49%)
loud environments (48%)
heat (47%)
caffeine withdrawal (43%)
alcoholic beverages (42%)
large groups of people (28%)
bananas (6%)

More than 65% of migraine sufferers have tried acetaminophen (Tylenol®), but it doesn’t work very well for most people. Over 20% of people have tried an alcoholic beverage, even though it typically makes migraines much worse. In contrast, less than 20% of people have tried wrapping a cold towel around their head, and yet it is one of the more effective treatments listed by migraine sufferers on CureTogether.

Treatments rated as most effective for patients with migraine
1. Dark, quiet room
2. Sleep
3. Eliminate red wine
4. Passage of time
5. Eliminate MSG
6. Avoid smoke
7. Wear sunglasses
8. Intravenous DHE
9. Imitrex injection
10. Ice packs

According to 23andme, “When symptom data and treatment data come together, powerful things happen. Data from nearly 3,500 CureTogether members tell us that those who experience vertigo or dizziness with their migraines are three times more likely (18% vs 6%) to have a negative reaction to Imitrex®, a sumatriptan medication that is often prescribed for migraine sufferers”.

A word of caution about 23andme. I personally submitted my saliva for testing and completed many questionnaires to help with their research. However, some feel that 23andme’s promises of not sharing personal genetic information with anyone else could be undermined in the future, as it happened with Google. Here is an interesting blog post from the Scientific American on this topic entitled, 23andMe Is Terrifying, but Not for the Reasons the FDA Thinks
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About 12% of the population suffers from migraines. In addition to high rates of migraine-related disability, migraineurs are at a higher risk than the general population of additional disability related to depression, anxiety, irritable bowel syndrome, fibromyalgia, and other conditions.

Fibromyalgia is a disorder of the central nervous system with increased brain excitability. It often manifests itself not only with muscle pains, but also fatigue, memory problems, and sleep and mood disturbances. Various studies estimate that anywhere from 2% to 8% of the general adult population suffers from fibromyalgia. Just like with migraine, women are more often affected than men. The likelihood of coexisting fibromyalgia increases with increasing frequency and severity of migraine attacks.

Both migraine and fibromyalgia have been individually linked with increased risk of suicide. However, it is not clear that the risk is more than additive.

A study just published in Neurology, reports that patients with migraine and coexisting fibromyalgia have a higher risk of suicidal ideation and suicide attempts compared with migraine patients without fibromyalgia.

The study looked at 1,318 patients who attended a headache clinic. Of these patients, 133 or 10% were found to also have fibromyalgia. Patients with both conditions had more frequent, more severe, and longer-lasting migraine attacks as well as higher use of abortive medications.

Compared with migraine patients who did not have fibromyalgia, those with fibromyalgia were more likely to report suicidal ideation (58% vs 24%) and suicide attempts (18% vs 6%).

This report suggests that migraine and fibromyalgia may magnify the risk of suicide compared with the risk of the individual conditions. However, because this data comes from a specialty headache clinic, many patients were severely affected by their migraines, with more than 35% having chronic migraine. It is likely that the results would be less dramatic among migraine sufferers in the general population. Almost half of the estimated 35 million migraine sufferers in the US do not consult a physician. Most of them suffer from milder migraines than those who do consult a doctor.

This study suggests that patients with migraine should be evaluated for other chronic pain conditions and for their mental health well-being. In particular, patients with chronic migraine should be screened for other painful conditions and mental illness. And patients with fibromyalgia should also be evaluated for migraine and potential suicide ideation. Patients often do not appear depressed, but simple questions can detect depression, which can lead to effective treatment. Our initial evaluation at the New York Headache Center includes two questions which are highly indicative of depression: 1. Have you been bothered a lot in the last month by feeling sad, down, or depressed? 2. Have you been bothered a lot in the last month by a loss of interest or pleasure in your daily activities?

Antidepressants have been proven to be effective for the prevention of migraines even in the absence of depression and are the best choice for people suffering from both conditions. Prozac, Lexapro and other SSRI antidepressants do not help migraines or pain, but SNRIs such as Effexor, Cymbalta, and Savella or tricyclics such as Elavil, Pamelor, and Vivactil do relieve pain and depression.

Magnesium deficiency is common in both migraines and fibromyalgia and we recommend an oral supplement to all patients. Some patients do not absorb magnesium and respond very well to monthly intravenous infusions of magnesium. Both their migraines improve as do fibromyalgia symptoms.

One interesting difference between migraines and fibromyalgia is the response to Botox. Botox is proven to be highly effective for the prevention of migraines and it works very well to relax spastic muscles. However, Botox appears to be ineffective for the treatment of muscle spasm in fibromyalgia. It is possibly explained by the fact that Botox interferes with the function of acetylcholine, a neurotransmitter involved in contracting healthy muscles. In fibromyalgia, studies suggests a deficit in acetylcholine, so further blocking it would be ineffective or even make the muscle pain worse (which I’ve seen in a few patients).

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MRI scans of migraine sufferers are almost always normal. Occasionally we see white spots on the MRI, which can be also found in people with high blood pressure, dementia, and sometimes in perfectly healthy people (see my previous post on this).

However, Mayo Clinic neurologists, led by Dr. Todd Schwedt reported being able to diagnose chronic migraines on the MRI scan. The accuracy of the diagnosis of those who had 15 or more headache days each month was fairly high – 84%. Patients with this frequency of attacks are considered to be suffering from chronic migraines. However, they could diagnose only 67% of those with episodic migraines (less than 15 headache days each month). The researchers used sophisticated software (FreeSurfer) that measured the surface area, thickness, and volume of 68 various brain regions and discovered that changes in 6 of these regions were predictive of migraine diagnosis. These 6 regions participate in pain processing in the brain and include the temporal lobe, superior temporal lobe, anterior cingulate cortex, entorhinal cortex, medial orbital frontal gyrus, and the pars triangularis. The software used in the study is freely available, but using it is time consuming and it is utilized only by researchers and not by any hospital or private MRI facilities.

Their findings confirmed what until now was an arbitrary decision by headache experts to divide migraines into episodic and chronic ones with a 15 day cutoff. Ahother study by Dr. Richard Lipton and his colleagues at the Montefiore headache clinic has found that those who have 10 or more headache days each month have many similar features compared to those who have less than 10.

This is not a purely academic question. Insurance companies will pay for Botox only if a patient has 15 or more headache days each month because this type of patients was used in clinical trials of Botox. However in practice we also see very good response to Botox in patients who have fewer than 15 days.

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

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

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

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

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

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

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

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

I would add that to make this diagnosis, other known potential causes of fatigue should be ruled out. These include thyroid disease, anemia, chronic infections (Lyme and other), vitamin B12 and other deficiencies. As mentioned in a previous post, the test for vitamin B12 is not very accurate. Many laboratories list normal levels being between 200 and 1,000. However, many patients with levels below 400, and some even with levels above 400 still have a deficiency. If a deficiency is strongly suspected, additional tests are needed – homocysteine and methylmalonic acid levels.

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A report by Taiwanese doctors just published in the journal Neurology suggests that having migraine headaches may double the risk of Bell’s palsy.

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

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

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

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

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

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

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Cyclic vomiting syndrome (CVS) is usually seen in children. The attacks of vomiting often stop as the child gets older, but then they usually go on to develop migraine headaches. A recent report in Headache describes three adults with CVS. The article also mentions a previous report which described another 17 adults with this syndrome.

CVS typically consists of recurrent stereotypical attacks of incapacitating nausea and vomiting, separated by symptom-free periods. Supporting evidence that helps diagnose this condition include personal or family history of migraine and other symptoms, such as headaches, motion sickness, and sensitivity to light.

Just like in children, CVS in adults is a diagnosis of exclusion, meaning that other causes of vomiting must be considered and ruled out. I mentioned in a previous post that one out of three children with CVS turned out to have another medical problem rather than migraine.

CVS in adults seems to respond well to an injection of sumatriptan (Imitrex). This allows for a quick relief of symptoms and makes this debilitating condition very manageable. Besides Imitrex injections, Zomig (zolmitriptan) nasal spray can sometimes be effective as well.

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

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

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

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

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

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

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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.

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

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

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

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

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

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

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

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

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

This post contains direct quotes from collective-evolution.com

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

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

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

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

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

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The benign nature of white matter lesions (WML) on MRI scans of patients with migraine was noted in a post last year. While they appear to be benign, they are disconcerting nevertheless. It is possible that we haven’t yet discovered the negative effects they may have.

A study by Chinese researchers published in the Journal of Neurology reported on MRI scans in 141 people, including 45 healthy controls without migraines, 38 chronic migraine sufferers who were not overusing acute migraine medications and 58 patients with chronic migraines who were overusing these medications. They found that women, but not men, who were not overusing acute medications had more WML compared with controls and those who were overusing medications. As reported by other researchers, the number of WML increased with age. Interestingly, most patients who overused medications were taking non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen and naproxen. The authors concluded that taking NSAIDs may have a preventive effect on the development of WMLs, possibly because of their anti-inflammatory properties. Previous studies have shown that aspirin does not even cause medication overuse headaches, unlike drugs with caffeine (Excedrin, Fiorinal, Fioricet), opioid analgesics (Vicodin, Percocet, codeine, etc), and to a lesser extent NSAIDs.

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

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

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

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

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

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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.

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

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

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

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

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

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

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


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

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

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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.

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More patients with fibromyalgia suffer from migraine headaches than those without this fibromyalgia. Those with fibromyalgia are also more likely to have irritable bowel syndrome, depression, and panic attacks. Fibromyalgia has been a mysterious and an ill-defined condition. However, after years of research specific criteria for the diagnosis were developed and several drugs for fibromyalgia were approved by the FDA (Lyrica, Cymbalta, Savella).

A new study by researchers at the Massachusetts General Hospital suggests that half of the patients with symptoms of fibromyalgia have damaged peripheral nerves, a condition called small-fiber neuropathy. They compared skin biopsies (a test to diagnose the neuropathy) in 25 patients with fibromyalgia and 29 healthy controls. In healthy controls only 17% had neuropathy. This type of neuropathy can also occur in diabetics, but none of the 25 patients in the study had diabetes. Other conditions that can cause small-fiber neuropathy are cancer, autoimmune conditions, various toxins, vitamin B12 deficiency, and genetic disorders, but none of these were present either, except for possibly genetic cause since three patients were related (a mother and two daughters).

The practical importance of this finding is that sometimes neuropathy responds to immune therapies, such as intravenous gamma globulin.

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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.

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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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The previous post mentioned a study confirming that caffeine makes headaches worse in adults 20 years or older. A study by pediatric neurologists from the Cleveland Clinic, Chad Whyte and David Rothner showed that this is also true in adolescents. They looked at 50 children, who were between 12 and 17 years of age who presented to their headache clinic. The average age was 15 and 64% were girls. The mean consumption of caffeine was 109 mg per day. In kids with chronic migraines the intake was 166 mg, while in the rest it was 65 mg. The most popular form of caffeine was soda drinks. This study further confirms the role of caffeine in causing worsening of headaches and leading to chronic migraines.

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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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Dihydroergotamine (DHE-45) is considered to be the most effective injectable migraine drug. In addition to injections, it is been available in a nasal spray form (Migranal), but the nasal spray is much less effective than the injection. Early next year we expect to have an inhaled version of dihydroergotamine, Levadex. Clinical trials indicate that it could work as fast and as well as the injection and may have fewer side effects. Dihydroergotamine constricts blood vessels and just like triptans (Imitrex or sumatriptan and other) is contraindicated in people with cardiovascular disease, such coronary artery disease, heart attacks, and strokes. The perception has always been that dihydroergotamine, because it is a less pure drug than triptans, is a stronger vasoconstricter than triptans. However, a recent study by Dutch researchers suggests that this may not be the case.

This study compared the contractile effects of sumatriptan and DHE in human coronary arteries. The study looked at both large (proximal) and small (distal) coronary arteries. The arteries (removed from the body) were exposed to sumatriptan (Imitrex) and DHE. In larger (proximal) coronary artery segments sumatriptan was a stronger constricter than DHE but the difference was not significantly different. In contrast, in smaller (distal) coronary arteries, the contractile responses to sumatriptan were significantly larger than those to DHE. At clinically relevant concentrations contractions to both sumatriptan and DHE in proximal as well as distal coronary arteries were below 6%. The researchers concluded that coronary artery contractions to DHE in distal coronary artery are smaller than those to sumatriptan, although in the clinical situation both drugs are likely to induce only a slight contraction. So, both drugs are relatively safe and dihydroergotamine may be safer than sumatriptan, although both should not be given to migraine sufferers who also have cardiovascular disease or multiple risk factors, such as hyprtension, diabetes, high cholesterol, smoking, and other.

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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.

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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.

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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.

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Surprisingly, Botox appears to relieve hemiplegic migraines, according to a report by two neurologists from the Mayo Clinic.

They describe 5 female patients who suffered from very frequent and severe migraine headaches with four of them having chronic migraines, that is had headaches on 15 or more days each month. The headaches were preceded and/or accompanied by weakness of one side of their body. The weakness lasted only 20 minutes in one patients, but for hours and days in others. All five patients were first treated with prophylactic medications, which either did not help or caused unacceptable side effects. Botox injections were given every 3 months into the usual sites around the scalp, neck and shoulders. A total dose of 150 units was injected. Three of the patients had three sets of injections by the time of this report and they continued to respond well.

Migraine with typical visual auras has been reported to respond well to Botox injections, which is also somewhat surprising since Botox appears to work on the sensory nerves. This effect on sensory nerve endings leads to the relief of pain. It is likely that reducing painful episodes in turn leads to a calming effect on the brain in general and the brain stops generating migraines as well as symptoms associated with migraines.

I have also seen many patients with visual, sensory and motor aura respond well to Botox injections, often when prophylactic drugs had been ineffective.


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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.

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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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Botox is approved by the FDA for the prophylactic treatment of chronic migraine headaches. Chronic migraine was arbitrarily defined by headache researchers as headache occurring on more than 14 days each month. Epidemiological research by Dr. Richard Lipton and his colleagues at the Albert Einstein School of Medicine suggests that there is no biological difference between frequent migraines that occur on 10 or more days each month and chronic migraines.

They compared clinical features and the incidence of other chronic medical conditions in three groups of patients with migraine: low frequency (0-9 days/month), high frequency (10-14 d/mo) and chronic migraine (15-30 d/mo). The American Migraine Prevalence and Prevention Study is a US-population-based study with 16,573 people with migraine who responded to a 2005 survey. Of these, 10,609 had low frequency, 640 had high frequency and 655 had chronic migraines. Rates of pulmonary and respiratory conditions including asthma, bronchitis, chronic bronchitis, emphysema/COPD, allergies/hay fever, and sinusitis increased across headache frequency groups and were significantly different for chronic migraine vs. low frequency, but not for chronic migraine vs. high frequency. A similar finding was seen for cardiac conditions and strokes. Depression, nervousness or anxiety, bipolar disorder/mania, and chronic pain were also much more common and similar in those with frequent or chronic migraine compared to those with low frequency migraines (around 30% vs 15%-18%).

These findings suggest that patients with frequent migraines resemble those with chronic migraines much more than they do those with low frequency migraines. One practical implication of this research is that Botox is very likely to be as effective for patients with frequent migraines (those with 10-14 headache days a month) as it is for patients with chronic migraines. And indeed, I’ve observed an excellent response in patients with frequent migraines in my almost 20 years of giving Botox injections for headaches. The response for both patients with frequent migraines and chronic migraines is about 70%, which significantly exceeds the efficacy of any prophylactic drug with no potentially serious side effects seen with most drugs.

Art credit: JulieMauskop.com

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Female pelvic/genital pain is more common in women with chronic Headache, according to a study presented by Canadian neurologists.
The study was carried out by researchers and clinicians at the Wasser Pain Management Centre, Mount Sinai Hospital and the Centre for Headache at Womens College Hospital in Toronto, Canada. During the study period, every adult English speaking female patient at the Centre for Headache at WCH was asked if they would consent to complete a specifically devised questionnaire. Of the 72 completed questionnaires, 32 (44%) of patients reported that they had pelvic region or genital pain brought on by sexual activity. Thirteen (18%) admitted to having pelvic pain that prevents them from engaging in sexual activity. 46% of these women had not had treatment, 39% were currently being treated, and 15% said they had received treatment in the past. All but one said that she would be interested in receiving treatment if available. The researchers concluded that it is important to ask women with chronic headache about sexual pain and, if present, be able to offer a management option.

Art credit: JulieMauskop.com

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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.

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German researchers examined the possible connection between headaches and low back pain in a study published in the recent issue of journal Pain. They questioned 5605 headache sufferers about the frequency and type of their headaches and about the frequency of their low back pain. Of these 5605 people 255 (4.5%) had chronic headache and the rest had episodic (less than 15 headache days each month). Migraine was diagnosed in 2933 subjects, of whom 182 (6.2%) had chronic migraines. Tension-type headache was diagnosed in 1253 respondents, of whom 50 (4.0%) had chronic tension-type headaches. They also found that 6030 out of 9944 people suffered from back pains, of whom 1267 (21.0%) reported frequent low back pain. The odds of having frequent low back pain were between 2.5 times higher in all episodic headache subtypes (migraine and tension) when compared to those without any headaches. The odds of having frequent low back pain were 15 times higher in all chronic headache subtypes when compared to those without headaches. One possible explanation for this association is that having pain in any part of your body makes you more likely to develop other types of pain. We know that persistent pain makes the nervous system more excitable and this in turn may predispose to other pain syndromes. We also know that people with fibromyalgia are more likely to suffer from headaches, and those with migraines are more likely to develop painful irritable bowel syndrome.

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


Art Credit: JulieMauskop.com

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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.
hearing loss migraine
Photo credit kids-ent.com

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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.
running
Photo credit: Run Wild Retreats

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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.
Yaz
Ortho Evra

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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.

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Aspirin is by far the most effective drug for the prevention of migraine with aura, according to Italian researchers from Turin. They reported on 194 consecutive patients who had migraine with aura and who were placed on a prophylactic medication. Ninety of these patients were on 300 mg of aspirin daily and the rest were given propranolol (Inderal), topiramate (Topamax), and other daily medications. At the end of 32 weeks of observation 86% of those on aspirin had at least a 50% reduction in the frequency of attacks of migraine with aura compared with their baseline frequency, while 41% had even better results – at least a 75% reduction. In contrast, only 46% of patients on other drugs had a 50% improvement in frequency. The probability of success with aspirin was six times greater than with any other prophylactic medication, according to the lead author, Dr. Lidia Savi.
Aspirin is not only effective for the prevention of migraines with aura but also for acute therapy of migraine attacks. In previous posts I mentioned that a rigorous analysis of large numbers of patients showed that 1,000 mg of aspirin is better than 500 mg of naproxen (2 tablets of Aleve) and that 1,000 mg of aspirin was as good as 100 mg of sumatriptan (Imitrex) with fewer side effects.
Many health benefits of aspirin, which was originally derived from the willow bark, are becoming widely known. In addition to helping prevent heart attacks and strokes, aspirin has cancer-fighting properties. You may want to read a very interesting article about aspirin, The 2,000-Year-Old Wonder Drug, just published in the New York Times.
Willow
Aspirin formula

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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.

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Exercise-induced headaches are thought to occur more often in people who do not exercise regularly and my usual recommendation is to exercise regularly, starting with low intensity and short duration exercise sessions. If headache occurs with minimal exertion, I suggest taking Advil (ibuprofen), Aleve (naproxen), Migralex (aspirin/magnesium) an hour before exercise for several weeks. However, it appears that even experienced athletes suffer from what is officially known as a primary exertional headache. Dutch researchers are reporting on the incidence of exercise-related headaches among cyclists in the latest issue of journal Headache. They performed an online survey of 4,000 participants of a very challenging cycling race. Thirty seven percent of them suffered from such headaches at least once a month and 10% had them at least once a week. Women were more likely to have these headaches – 54% vs 44% in men. Older cyclists were significantly less likely to have these headaches. Tension-type and migraine headaches were most common. Headache medications were used by 37% of participants. Extreme exertion was the most commonly reported contributing factor (50%), while some reported that low fluid intake (39%) and warm weather (39%) contributed to their headaches; 26% could not identify their trigger. Another possible trigger not reported in the article is neck strain. Riding sports bikes with low handlebars makes riders strain their neck and trigger a cervicogenic headache.
The authors concluded that these headaches are widely underestimated and may cause many people quit their sports. They also called for research into causes and treatment of exercise-related headaches.cycling

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Erythromelalgia is a rare, often inherited pain syndrome which causes pain and redness of hands and feet. I just saw another woman who had both erythromelalgia and migraines. My observation of several patients who had both diseases does not mean that these conditions are connected since migraines are very common in the general population. However, magnesium is known to help both conditions, so it is possible that there are common underlying causes. In fact, a sodium channel mutation which is responsible for erythromelalgia was also found in a family with familial hemiplegic migraine. Magnesium is involved in the regulation of sodium channels (as well as calcium and potassium channels) in all cells of the body. Most people who are deficient in magnesium and suffer from erythromelalgia and/or migraines respond well to oral magnesium supplementation, but a small percentage requires monthly intravenous infusions. We give intravenous infusions to those patients who do not tolerate oral magnesium (get diarrhea or stomach pains), those who do not absorb it (as evidenced by persistently low RBC magnesium levels) and those who prefer a monthly infusion to taking a daily supplement.Erythromelalgia

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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. Vaginal contraceptive ring

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

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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.

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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.

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Migraine aura is a visual disturbance that usually precedes the headache in about 20% of migraine sufferers. Migraine auraThe 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. Migraine auraMost 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.

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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.

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Restless leg syndrome (RLS) is more common in women who also suffer from migraines, according to a new study published in the journal Cephalalgia. Women with migraines are 20% more likely to also have RLS. This study involved 31,370 US health professionals making its findings highly reliable. In my previous post 5 years ago I mentioned that RLS, by disrupting normal sleep, may increase the frequency and severity of migraines, but at that time we did not know that these two conditions are connected. Possible causes of this association include the fact that disturbance of metabolism of iron and dopamine in the brain is thought to play a role in both conditions. People who have symptoms of RLS should be tested for iron and vitamin B12 deficiency which can cause similar symptoms. A sleep study is sometimes necessary to confirm the diagnosis of RLS. This study involves sleeping in a sleep lab with wires attached to the scalp, monitors measuring breathing and video camera recording movements of legs and body. Most major hospitals have a sleep lab and it is usually covered by insurance.
Fortunately, we have many effective drugs to treat RLS – Requip (ropinirole), Mirapex (pramipexole), Horizant (gabapentin), Neupro patch (rotigotine), as well as opioid drugs, such as Vicodin (hydrocodone), Percocet (oxycodone), and other. Horizant is a long-acting form of gabapentin, which is available in a short-acting form as a generic, much cheaper form. The advantage of gabapentin (also known as Neurontin and Gralise) is that it has also been shown to prevent chronic migraine, so this one drug can potentially treat RLS and migraine.

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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.

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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.

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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.

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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”.

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Mal de debarquement syndrome (MdDS) or disembarkment syndrome is a rare condition which often, but not always, occurs after getting off a ship. Many people have “sea legs” after getting off a boat, but in most this sensation of still being on a rocking boat quickly subsides. Very few unfortunate people continue to have this sensation for months and even years. Last week I happened to see two patients with this condition. It was not entirely a coincidence since both read online report by a patient whom I helped. One woman I saw today said that she feels that her life was taken away from her. Despite her symptoms, she was able to hold a full-time job and care for her 3 children. However, the second patient with the worst case of MdDS I’ve seen, demonstrated how debilitating this seemingly minor disorder can be. She had to quit her job, became very anxious and depressed, which never happened to her before this illness. She also reported feeling very tired, could not think clearly, complained of difficulty breathing, diarrhea, constipation, and had many other debilitating symptoms. When I examined her, she was unable to stand with her feet together and eyes closed and could not walk a straight line, heel-to-toe. Almost all patients I’ve seen with MdDS had extensive testing, which was normal. Vestibular rehabilitation seems to help a few, as does acupuncture, or medications such as Klonopin or clonazepam (which seems to be the most commonly prescribed drug). Most of the patients with MdDS also suffer from headaches, often migraines. Even if they don’t have headaches, they are referred to me because the ENT or the primary care doctor thinks that this condition may be related to migraines. It is true that migraine sufferers are more likely to have disorders of the inner ear and difficulties with balance and coordination.
Our research has shown that up to 50% of migraine sufferers are deficient in magnesium and this deficiency is not detectable by routine magnesium test. Other symptoms suggestive of magnesium deficiency include coldness of extremities, or just being cold most of the time, leg or foot muscle cramps (often occurring at night), brain fog or spaciness, difficulty breathing, and other symptoms. Most of the patients with MdDS I’ve seen had many of these symptoms and what made a dramatic difference for more than half was an infusion of magnesium, often combined with a vitamin B12 injection (another common deficiency). Some patients were already taking oral magnesium supplement, but it did not make a difference. This is not unusual because some people have either a genetic inability to absorb oral magnesium or have gastro-intestinal disorders (irritable bowel syndrome, diarrhea, etc) which impair magnesium absorption. Some people need to have repeated monthly infusions of magnesium.
Another common contributing factor to this syndrome is neck muscle spasm, which alone can be responsible for a sense of dizziness, but more often just makes MdDS worse. Treatment of neck muscle spasm can produce significant improvement.
So, what happened to my two patients from last week? The first one felt only a little better right after the infusion and I asked her to call me back in a week or two, while the second one had a dramatic improvement: she could stand still without swaying with her eyes closed and walked a straight line without difficulty. We’ll see if this improvement will last. I suspect that it will. I also encouraged her to slowly get off clonazepam and an antidepressant she was taking, but to continue seeing a social worker for psychotherapy. I recommended to both patients several supplements, including CoQ10, 300 mg daily and 6 grams of omega-3 fatty acids.
If magnesium is ineffective, medications, such as gabapentin (Neurontin), memantine (Namenda), and tizanidine (Zanaflex) can help without causing habituation seen with clonazepam. For neck muscle spasm, isometric neck exercises that strengthen neck muscle can help. I also treated one patient who improved when I combined magnesium infusions with weekly acupuncture sessions. Acupuncture tends to be more effective with more frequent sessions, 2-3 times a week, which is impractical for many because of the time and cost involved.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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Aspirin is as effective as Imitrex (sumatriptan) in the treatment of migraine headaches with fewer side effects, according to an authoritative Cochrane review published earlier this year.  The review examined 13 high-quality studies which involved 4,222 patients.  Having such a large number of patients in well-conducted studies makes the data highly reliable.  Some of the studies utilized 900 mg of aspirin and some 1,000 mg, some with and some without a nausea medicine, metoclopramide (Reglan).  Aspirin was compared to both Imitrex, 50 or 100 mg and placebo.   The authors concluded that “there are no major differences between aspirin with or without metoclopramide and sumatriptan 50 mg or 100 mg. Adverse events with short-term use are mostly mild and transient, occurring slightly more often with aspirin than placebo, and more often with sumatriptan 100 mg than with aspirin.  In a previous post I mentioned the review of 16 studies of naproxen sodium (Aleve) for the treatment of migraines.  That review found that aspirin was more effective for the treatment of migraines than naproxen sodium (Aleve).  So far, aspirin seems to be the best drug for the initial treatment of migraine headaches.  However, there are many sufferers with severe migraines who do not respond to aspirin and there is a clear need for prescription drugs, such as Imitrex, although they do have a higher risk of side effects.  New migraine drugs are being developed with the goal of reducing the incidence of side effects, while improving their efficacy.  One of the new category of drugs being developed are CGRP antagonists, but they are at least 2 years away from becoming available.

 

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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.

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There are over 4 million chronic migraine sufferers in the US.  Chronic migraine is defined as a headache with migrainous features, which occurs on more than 15 days each month.  Many of these chronic migraine patients we see at the New York Headache Center have daily headaches.  By the time they come to our Center, many have seen several doctors, including neurologists and found no relief from a variety of drugs.  A new book just published by Oxford University Press may help doctors who care for headache patients to provide better care.  The book is Refractory Migraine, Mechanisms and Management.  Dr. Mauskop and Dr. Sun-Edelstein contributed a chapter to this book: Nonpharmacological Treatment for Refractory Migraine: Acupuncture, Vitamins and Minerals and Lifestyle Modifications.  An important message contained in the chapter and the one we always stress to our patients is that the best way to approach a refractory headache is not by trying one drug after another, but by combining drugs with nonpharmacological treatments, such as biofeedback, magnesium, other supplements, Botox injections, acupuncture and other therapies.

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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.

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Vertigo is a common complaint of migraine patients.  Ear-nose-throat specialists at the University of Pisa examined 22 patients with migraine headaches who complained of vertigo and 22 who did not, as well as 22 control subjects without migraines.  They found that in both groups of patients with migraines a third had abnormal vestibular function on laboratory testing.  In half of the patients in both groups the abnormality was in the inner ear (peripheral dysfunction) and in half in the brain (central dysfunction).  This study confirms that both central and peripheral vertigo are common in migraine patients, whether they complain of vertigo or not.  The most important question patients ask is what can we do about it.  Fortunately, once migraines are brought under control, vertigo also subsides.

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A recent study by Dr. Bigal and his colleagues just published in Neurology compared more than 6,000 migraine sufferers with over 5,000 matched control subjects without migraines.   They discovered that people with migraine with aura and to a lesser extent those with migraine without aura are significantly more likely to have strokes, heart attacks, hypertension, poor circulation, diabetes, and high cholesterol.  This clearly does not mean that migraine causes all these diseases, but only that if you have one you are more likely to have the other.  It is important to recognize this association in migraine sufferers in order to regularly screen them for these conditions.  We know that controlling diabetes, high blood pressure, and high cholesterol can prevent strokes, heart attacks and poor circulation in extremities.  We also recommend that women who have migraine with aura should not take estrogen-based oral contraceptives or hormone replacement therapy since estrogen in these women also increases the risk of strokes.  All migraine suffererss (and everyone else) should not smoke and exercise regularly, which also reduces the risk of the conditions mentioned above.

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During pregnancy, two thirds of women stop having migraine headaches.  However, one third continues to have them, and sometimes even worsen during pregnancy.   As a general rule, only acetaminophen (Tylenol) is considered safe, but for most migraine sufferers it is completely ineffective.  Codeine is also benign, but it also either does not work or causes side effects, such as nausea and sedation.  Triptans, such as sumatriptan (Imitrex), rizatriptan (Maxalt), and other are very effective for migraines, but are not proven to be as safe.  Pregnancy registries in the US have information on over 1,500 women who took a triptan during pregnancy and so far the drugs look safe for the baby.  A new study from Norway in the February issue of Headache reports on another 1,535 women who took triptans during pregnancy and compared them to 68,000 women who did not.  This study also found no increased risk of congenital malformation, even if triptans were taken in the first trimester.  Women who took triptans in the second and third trimester also had healthy babies, but they had a slightly increased risk of atonic uterus and bleeding during labor.

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Migraine and migraine medications do not appear to cause cognitive decline, according to a Dutch study just published in Headache.  After 6 years of follow-up there was no difference between those who suffered from migraines and healthy controls.  Taking migraine medications also did not have an effect on cognitive function.  This is very reassuring, especially because a recent study in rats suggested brain damage from what the researchers felt was a process similar to migraine.

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Migraines in blind people are made worse by light, according to Dr. Burstein and his associates at Harvard.  Rami Burstein is one of the leading headache researchers who often asks questions no one else thought to ask.  More importantly, he often finds the answers.  When he mentioned to me that he wants to find out why bright light makes headaches worse (so called photophobia), I immediately thought of a blind patient I was treating.  She was very interested in helping Rami discover the answer and helped him recruit many other blind migraine sufferers.  After several years of work, his finding were published today in Nature Neuroscience.  A recent discovery showed that in addition to rods and cones in the retina (cells that allow us to see), there are cells which react to light, but their input goes to non-visual parts of the brain.  These cells regulate sleep-wake cycle and, according to Rami Burstein’s research, also magnify pain perception in headache patients.

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The fact that two out of three pregnant women stop having headaches during pregnancy is well established, however a study by Norwegian researchers published in Headache provides some additional details.  Women with headaches who are pregnant for the first time tend to have fewer headaches than non-pregnant women or women during subsequent pregnancies.  This is especially true in the third trimester.   Non-pregnant women who had never been pregnant were less likely to have headaches than women who had been.  If a woman does have headaches during pregnancy, the initial treatment should consist of non-drug therapies, such as biofeedback or meditation, magnesium and other supplements, acupuncture, and if headaches are frequent, Botox injections.

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Childhood abuse or neglect was reported by 58% of 1,348 migraine sufferers according to a study published in the current issue of Headache.  Emotional abuse and neglect was particularly common.  Patients with other chronic pain conditions also have high incidence of emotional, sexual, and physical abuse.  Migraine patients who suffered abuse are also more likely to have anxiety and depression.  We do not know what physiological mechanisms that are triggered by abuse lead to chronic pain.  This and similar studies suggest that greater attention should be directed at the psychological factors that contribute to migraine headaches.  One possible negative outcome of this study is that some physicians, who may already consider migraine to be a purely psychological disorder, will be even more inclined to avoid treating migraine as a biological disease.  In practice, it means that these doctors will be even more reluctant to prescribe appropriate acute migraine medications, such as triptans (Imitrex and other).  Migraine is clearly a biological disorder with documented genetic predisposition and should be treated as such.  At the same time, we know that psychological factors play a major contributing role and should be also addressed when treating headache and pain patients.

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Migraine headaches are more frequent in people who suffer from allergic rhinitis and who have more than 10 positive skin allergy tests.  This finding by Dr. Martin and his colleagues presented at the International Headache Congress last week is not surprising since many of my patients report that their migraines worsen during periods when their allergies flare up.  It is also not surprising because almost any medical condition affecting the head, whether it is an ear infection, a dental problem, or conjunctivitis, can trigger a migraine attack.

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Migraine headaches are three times more common in patients with multiple sclerosis than in people of similar age and gender without MS.  Ilya Kister and his colleagues at NYU who established this fact make a very important point – multiple sclerosis symptoms often overshadow the symptoms of migraine and this can result in migraine not being treated properly leading to additional avoidable disability.    

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Vertigo can induce a migraine attack in migraine sufferers, according to a study published in Neurology.  In this study researchers induced vertigo in patients who had a history of migraines and in a control group.  Almost half of those who had a history of migraines developed a migraine attack within 24 hours, compared with only 5% of those who were not known to have migraines.  The study suggests that vertigo due to an inner ear problem can trigger a migraine attack.  This finding will not come as a surprise to migraine sufferers who cannot ride a roller coaster or even go on bumpy a car ride without getting a migraine.

At times, migraine sufferers develop vertigo as part of their migraine attack and it can be difficult to tell if vertigo caused the migraine or was just one of the symptoms.  A detailed description of more than one attack usually gives a clear answer.

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Good news for adolescents with chronic daily headaches (CDH) was reported by Taiwanese researchers followed 122 kids, aged 12 to 14 who were diagnosed with this condition.  A year later 40% still had CDH, and after 2 years, 25% had symptoms of CDH.  They followed 103 of the original 122 for 8 years and found that only 12% still had daily headaches with 10 out of 12 diagnosed as having chronic migraines.  This is what we see in practice, but now we have good evidence and can be more certain when we tell our adolescent patients and their parents that they will “grow out” of their headaches.  Another piece of good news was that most kids were not actively treated and headaches improved on their own.  However, it may take months or years for headaches to improve and we should not just sit and wait while the child suffers.  Active treatment includes sleep hygiene, regular exercise, avoiding dietary triggers, biofeedback or relaxation training, magnesium, CoQ10 and other supplements, possibly acupuncture, Botox injections and medications.

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

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Lower facial pain during a migraine attack occurs in 9% of migraine patients, according to a recent report published in Cephalalgia by German researchers.  One of the 517 migraine patients they looked at had lower facial pain as the leading symptom of migraine.  Some of my patients with lower facial pain wonder if they have a disorder of the temporo-mandibular joint (TMJ).   Some of them do benefit from an oral appliance that reduces grinding and clenching, in most however, a successful treatment of their migraines with abortive or prophylactic medications will often relieve the jaw pain as well.

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Headache diary plays an important role in the management of headache patients.  Drs. McKenzie and Cutrer from the Mayo Clinic compare patient recall of migraine headache frequency and severity over 4 weeks prior to a return visit as reported in a questionnaire vs a daily diary.   Here are some of their findings “Many therapeutic decisions in the management of migraine patients are based on patient recall of response to treatment.  As consistent completion of a daily headache diary is problematic, we have assessed the reliability of patient recall in a 1-time questionnaire.  209 patients completed a questionnaire and also maintained a daily diary over the 4-week period. RESULTS: Headache frequency over the previous 4 weeks as reported in interval questionnaires (14.7) was not different from that documented in diaries (15.1), P = .056. However, reported average headache severity on a 0 to 3 scale as reported in the questionnaire (1.84) was worse than that documented in the diaries (1.63), P < .001. CONCLUSIONS: In the management of individual patients, the daily diary is still preferable when available. Aggregate assessment of headache frequency in groups of patients based on recall of the prior 4 weeks is equally as reliable as a diary. Headache severity reported in questionnaires tends to be greater than that documented in daily diaries and may be less reliable. “

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A pharmacogenetic study by Italian researchers discovered that absence of a certain gene can predict therapeutic response in migraine patients who are treated with riboflavin (vitamin B2).   Pharmacogenomics has been a very promising field of medical science that may enable doctors to select the most effective and safe medicine for each patient based on their genetic profile.  This is a small but important step in utilizing this science to treat headache patients.

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Vertigo is a common symptom in patients with migraine headaches.  It appears that obverse is also true – migraine is very common in patients with vertigo.  A study just published in Cephalalgia looked at 208 patients with benign recurrent vertigo.  It turned out that 87%, or 180 of these patients had migraine headaches.  Of these 180 patients, 112 or 62% had migraine with aura and 38% had migraine without aura.  Thirty percent, or 54 patients always had vertigo without any migraine symptoms, while in 70% vertigo occurred with a headache or other migraine symptoms, such as visual aura, sensitivity to light and noise.  The duration of attacks of vertigo in most patients was between one hour and one day.

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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.

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Strokes in pregnant women who suffer from migraine headaches are very rare.  This is a letter I submitted to the British Medical Journal  in response to an article they just published on this topic:

The large amount of data and the statistical analyses in this paper look impressive and unfortunately may fool many readers into believing the conclusions made by the authors.  The authors do acknowledge that the discharge diagnostic codes miss many patients who suffer from migraine headaches.  This diagnosis is not only missed upon discharge, but it is an established fact that migraine is significantly underdiagnosed by the majority of primary care doctors.  Obstetricians are not likely to do a better job in distinguishing sinus and tension-type headaches from migraines, or diagnosing a migraine aura, particularly when managing a pregnant woman in the hospital.  It is true that migraines improve in pregnancy, but considering that about 18% of women suffer from migraine headaches, it is hard to believe that only one in 100 of these women will continue having migraines during pregnancy.  Obviously, when a complication, such as stroke occurs the diagnosis of migraine is much more likely to be recorded than when no complications occur. 
The authors provide many disclaimers and state that “On the basis of the select group of pregnant women with migraines coded during the hospital admission, this may not represent the population of women with migraine as a whole”.  Nevertheless, they go on to present and analyze this highly inaccurate data and even draw conclusions.  It is very unfortunate that the publicity associated with this paper (I first saw it reported on Yahoo.com) will cause unnecessary anxiety to millions of pregnant women. 

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Migraine headaches in patients with post-traumatic stress disorder tend to be more frequent and disabling, according to a study in soldiers led by Dr. Jay Erickson.  Soldiers with PTSD had almost twice as many headaches as soldiers without PTSD and were more likely to have chronic migraines (headaches on more than 15 days a month).  Treatment with preventive medications was slightly less effective in the PTSD group.  Botox injections were not tried in these patients.  It is a well established fact that patients with a history of abuse are more likely to have chronic pain, including headaches.  This is an important part of history since inclusion of psychotherapy may improve treatment outcomes in these patients and, at least in theory, using antidepressants rather than other classes of preventive drugs may be more appropriate.

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Both overweight and underweight people are more likely to have migraine headaches, according to a recent study published in journal Cephalalgia.  Being overweight has been shown to increase the risk of chronic migraines in a previous large study, but the discovery of the link between being too thin and migraines is new.  These findings do not mean that regaining normal weight will lead to improvement in headaches, but only that there is an association.  This is not to say that we do not encourage our overweight patients to lose weight.  The best way to achieve this is not only by dieting, but also by engaging in frequent aerobic exercise, which has been found to be associated with fewer migraine headaches. 

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Patients who suffer from migraine headaches are 30% less likely to develop breast cancer.  It is well established that fluctuating estrogen levels throughout the menstrual cycle can trigger migraine attacks.  These fluctuations are reduced during pregnancy and menopause, resulting in cessation of migraine attacks in two thirds of women.  At this point it is not clear what common estrogen-based mechanisms are responsible for the reduction of breast cancer risk in migraine sufferers.

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It is well known that if you take a snapshot of the population, about 18% of women and 6% of men suffer from migraine headaches.   However, a report by Dr. Stewart and his colleagues in the latest issue of Cephalalgia indicates that cumulative lifetime migraine incidence is much higher – 43% of women and 18% of men have migraine headaches at some point in their lives.  Migraine incidence peaked between the ages of 20 and 24 in women and 15 and 19 in men.  In 75% of cases migraine started before the age of 35.

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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.

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A study conducted by one of the leading headache researchers, Dr. Richard Lipton looked at possible factors that worsen migraine headaches.  The study looked at people with frequent migraines (15 or more days with headache a month) and found that these patients were more likely to be female, overweight, depressed, have a lower education level and overused medications.  The overused medications included narcotics, barbiturates (Fioricet, Fiorinal and Esgic) but also over-the-c0unter drugs such as Excedrin.  The only exception was aspirin – it appeared to be protective, that is people taking aspirin were less likely to develop chronic headaches.  Dietary caffeine and stresful life events were also more common prior to development of chronic migraines.

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For many years headaches were thought to be triggered by elevated blood pressure.  Evidence had suggested that only very sudden increase in blood pressure triggered a headache in some patients, but the myth of high blood pressure headaches has persisted.  Norwegian researchers published a very surprising finding in the April issue of journal Neurology.   They looked at the data on 120,000 people and found that increasing systolic blood pressure was associated with a decrease in migraine and non-migraine headaches.  Even more striking was the inverse correlation with the pulse pressure (difference between systolic and diastolic pressure, for example blood pressure of 110/80 means that the pulse pressure is 30).  Patients with higher pulse pressure had fewer migraine and other headaches.  It can be speculated that hardening of arteries that occurs with elevated blood pressure makes them less likely to constrict and dilate, which is part of a migraine process.

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Scientists in Trieste, Italy suggested a new approach to the treatment of migraine headaches.  They hypothesized that combining two different approaches would yield better outcomes than either one alone.  A neurotransmitter CGRP antagonists appear to be effective in the treatment of an acute migraine.  Merck has a product in late stages of development that works through this mechanism and hopefully will be the first of a new class of migraine drugs.  Based on laboratory research the Italian group suggests that combining a CGRP antagonist with a blocker of nerve growth factor may result in a more effective treatment.  This fits with a new trend in treatment of many conditions – combining drugs that work in different ways, rather than trying to always use a single medication.

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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.  

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For many years migraines have been thought to occur more often in left-handed people, but a new study from Germany disputes this theory.  A recent study published in journal Cephalalgia looked at 100 people with migraines and 100 controls and also reviewed five similar studies and found no difference in the incidence of migraines in left-handed and right-handed people.  This has been the observation at our headache clinic as well. 

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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.

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Migraine does not cause cognitive impairment, according to a new Danish twin study.  This important finding reassures millions of migraine sufferers and confirms our clinical observation.   Another recent study in mice suggested that inducing brain changes similar to what occurs during a migraine attack in humans can cause brain damage.  This report was widely circulated in the media and has caused unnecessary anxiety in many migraine sufferers.  Clearly, whatever those mice experienced was not a migraine attack and, more importantly, brains of mice are very different from human brains. 

The Danish study looked at 139 pairs of twins where one of the twins had migraines and the other one did not.  Comparing their cognitive abilities revealed no difference for those who had migraine with or without aura, even after taking into account age, age of onset, duration of migraine history and number of attacks.  Presence of aura is thought to indicate a more serious condition with a slight increase in the risk of stroke.  However, on one cognitive test, men with migraine with aura did better than their twin without migraines.

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A recent study published in Neurology showed that migraine sufferers have thicker gray matter in the part of the brain that perceives pain.  Thickening of the gray matter indicates larger number of brain cells in that area, which is not necessarily a bad thing.  However, all of the commentary in the media suggests that this is another indication of brain damage in migraine patients.  This study is not a cause for alarm and all of the previous research also indicates that the vast majority of migraine sufferers are not at risk of brain damage.

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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.

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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.

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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.

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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.

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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%.

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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)

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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.

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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.

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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.

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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.

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