We are in great need of better preventive treatments for migraines. CGRP monoclonal antibodies appear to fulfil their early promise. At the recent annual meeting of the American Headache Society four companies presented their data and it looks very good. The drugs are very effective and are likely to help about 60% of patients and what continues to surprise is their safety. Three of the four companies have completed their final, phase 3 trials and in a few months will submit their data to the FDA. The FDA has a year to decide whether to approve them, but considering their demonstrated safety and efficacy, there is no reason why they should not be approved.

Once they are approved, one issue that may pose a problem is the cost. I mentioned this in a previous post.

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We’ve adopted electronic medical records (EMR) over 10 years ago when the upfront costs were high and the training curve was steep. One of the reasons for our early adoption was that we were running out of space for paper charts in our small Manhattan office. We also knew that EMR would improve the quality of care and safety – it allows us to see the lists of problems, allergies, medications, and other information at a glance on one screen. Sending prescriptions electronically dramatically reduces errors and saves time. Being able to log onto our system from home improved the after-hours care of our patients. We’ve never regretted implementing EMR years before EMR was mandated by the government.

Now for the negatives. A recent study by Dr. Christine Sinsky and colleagues published in the Annals of Internal Medicine is entitled, Allocation of physician time in ambulatory practice: A time and motion study in 4 specialties.

For this study, fifty-seven ambulatory care physicians in four specialties (family medicine, internal medicine, cardiology, orthopedics) in four states were directly observed for 430 hours. Twenty of these physicians also completed after-hours diaries. The results were striking: physicians spent 27% of their time on direct clinical face time and 49% on electronic health records and deskwork, while the rest was spent on administrative and other tasks. Even in the exam room, physicians spent 53% of the time on direct clinical face time and 37% on electronic health records and deskwork. They also spent 1-2 hours each night after office hours devoted primarily to electronic health records completion. The authors determined that for every hour physicians spent in direct clinical face time with patients, they spent additional 2 hours on electronic health records and deskwork during the clinic day and 1-2 hours of personal time finishing up electronic health records and deskwork at night.

So, when you see a doctor or a nurse practitioner, keep in mind that in addition to the time he or she spends with you, they have to spend twice as much time typing information into the computer, completing disability, insurance, and other forms, speaking to doctors and pharmacists, answering emails, staying up-to-date with latest medical discoveries, and doing other work. Dr. Neil Busis, writing in Neurology Today comments that the study confirms what we already know, that EHR use adds considerable clerical burden to practice. The study authors found that the use of EMR have decreased satisfaction and increased the risk for professional burnout. Physicians who burn out are at a significantly greater risk for depression and are more likely than satisfied colleagues to provide lower-quality patient care and to leave clinical practice early. Dr. Busis also notes that for many years the Centers for Medicare and Medicaid Services were telling doctors that they are not interested in listening to complaints until doctors can demonstrate that their policies will adversely affect their beneficiaries by decreasing access to care. This study provides such information. The idea is not to stop using EMR, but to reduce the need for meaningless tasks and to provide adequate compensation which accounts for all of the tasks doctor completes and not only for the face to face encounters.

I want to stress that, at least in our office, replacing paper charts with EMR has improved care of our patients, which in turn made our work even more satisfying. However, we would also love to spend less time doing paperwork.

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Vestibular migraine has been also called migraine-associated vertigo or dizziness and migrainous vertigo. Diagnostic criteria, according to the international headache classification, include a current or past history of migraine with or without aura, attacks lasting between 5 minutes and 72 hours, vestibular symptoms of moderate or severe intensity. These vestibular symptoms include spontaneous vertigo, positional vertigo occurring after a change of head position; vertigo triggered by a complex or large moving visual stimulus, head motion-induced vertigo occurring during head motion, head motion-induced dizziness with nausea. There is also a requirement for at least half of episodes to be associated with a typical migraine headache or visual aura.

These criteria are the result of a consensus arrived at by headache specialists, which makes them based on cases seen by these specialists, rather than large scientific studies. I’ve encountered some patients who do not have migraine headaches or visual auras, but probably still suffer from migraine-related dizziness or vertigo.

We also lack any studies of treatment for patients with vestibular migraine. My own observation is that vestibular symptoms improve with the treatment of migraine headaches. In patients who suffer from vestibular symptoms with few or no headaches we try similar treatments first – magnesium, CoQ10 and other supplements (we often check blood levels of RBC magnesium and CoQ10), regular aerobic exercise, and medications, such as gabapentin and nortiptyline. When headaches are very frequent we give Botox injections, which are not appropriate if headaches are infrequent.

The classification of headaches also lists benign paroxysmal vertigo as a condition which occurs in children and which may be associated with migraines. (This is different from benign positional vertigo which is triggered by a loose crystal in the inner ear and which can be cured with the Epley maneuver). This migraine-related vertigo usually occurs without a warning and resolves spontaneously after minutes to hours without loss of consciousness. Patients usually have one of the following features: nystagmus (beating movement of the eyes to one side), unsteadiness, vomiting, paleness, or fearfulness. The neurological examination, audiometry (hearing test) and vestibular functions (test also done by an ENT specialist) are normal between attacks.

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An ENT colleague recently referred to me a patient with very persistent sensation of pressure in her sinuses. She’d had sinus surgery which relieved pain in one of her sinuses, but the pressure sensation persisted. She did not experience much pain, but the pressure was present constantly and was very distracting and upsetting. First we tried intravenous magnesium because her blood test showed a mild deficiency. This did not help and I gave her several acupuncture treatments, which helped only a little and the effect did not last. When she mentioned that sneezing helped for a brief period, I though that intranasal hot pepper extract, capsaicin could help, and in fact it did.

There are several over-the-counter nasal sprays containing capsaicin, but she found that only Ausanil brand was helpful. Other brands include Sinol and SInus Buster. Ausanil is being advertised for both sinus and migraine headaches. There only small studies showing that capsaicin applied into the nostril can relieve migraines and even cluster headaches. A small Italian study showed that if capsaicin is applied into the nostril on the side of the headache it helped, but when applied on the opposite side, it did not.

This is not an easy treatment because it causes severe burning and some people tolerate it well, while other do not. It is certainly safe and inexpensive.

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Chronic migraine afflicts more than 4 million Americans, but shockingly less than 5% of them receive appropriate care, according to a new study just published in the journal Headache.

Chronic migraine sufferers experience headaches on more than half of the days and some, every day. These headaches are much more disabling than episodic migraines (those occurring on less than half of the days).

The study established three barriers to an effective treatment of this very common and very disabling condition. The first barrier was being able to see a specialist for a consultation. Those patients who were more likely to get a consultation were older, had more severe migraine symptoms, more disability, and had health insurance.

The second barrier is getting a correct diagnosis. Consulting a specialist rather than a primary care provider, being a female and having more severe migraines increased the odds of a correct diagnosis.

The third barrier was getting proper treatment with preventive medications and Botox injections and acute treatment with triptans and prescription nonsteroidal anti-inflammatory drugs (NSAIDs).

Only 56 (4.5%) out of the 1254 patients evaluated in the study overcame all three barriers and were given appropriate treatment. In a previous study, the same authors found that 26% of patients with episodic migraines traversed all three barriers, which means that only one of of four of more then 30 million Americans with episodic migraines received proper treatment.

The first barrier is possibly the most difficult to eliminate. Despite the fact that the Obamacare provided millions of people with insurance, access to doctors has improved only marginally. A sudden increase in the number of insured was not matched by an increase in the number of doctors. The main bottleneck is not the number of doctors who graduate from medical schools, but the number of residency training positions. Residency training is subsidized by Medicare, which has not increased the number of residencies. We do have a growing number of nurse practitioners and other non-physician healthcare providers who will hopefully make the shortage of doctors less acute. However, this study suggests that migraine sufferers need to see a specialist to receive a correct diagnosis. This does not necessarily mean a physician – we have three nurse practitioners who specialize in treating headaches and who are highly qualified to diagnose and treat various headache disorders.

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Zecuity, a transdermal sumatriptan patch has been reported to cause skin burns and scarring, according to the FDA. The FDA has started an investigation, but the manufacturer, Teva Pharmaceuticals has decided to pull the product off the market.

This is not a major loss for migraine sufferers since we now have four other ways to deliver sumatriptan (Imitrex) – tablet, injection, nasal spray, and nasal powder.

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Dr. Leo Galland, whom I’ve known professionally for many years, has written (with his son) another outstanding book, The Allergy Solution. Sometimes I see a patient, who in addition to migraine headaches, suffers from a variety of other ailments. These patients usually see an allergist, an ENT doctor, an infectious disease specialist, and several other physicians, all without answers or relief. In most cases, Dr. Galland is the one who can figure out what’s wrong and how to fix it.

Dr. Galland’s new book, which I just read cover-to-cover, presents scientific research that explains hidden causes of unexplained symptoms such as migraines, fatigue, weight gain, chronic pain, poor sleep, allergies, and reflux. The book describes the role of immune function, stress, nutrition, inflammation, environmental health, leaky gut, and the microbiome.

Most importantly, The Allergy Solution gives people practical solutions to relieve their symptoms, which are very often caused by allergies. Dr. Galland convincingly shows that allergies are aggravated by stress, abnormal gut bacteria, specific vitamin and mineral deficiencies, and other factors. He writes about scientific studies that show the effect of meditation on inflammation and how taking probiotics can improve not only your digestive problems but also migraines and many other symptoms. From this book you will learn the role of vitamin D, zinc, magnesium and a variety of other minerals and vitamins in returning you to health. One of the things I learned is that a combination of vitamin B12 and a mineral called molybdenum can reduce the amount of sulfites in your body. Sulfites, which often trigger migraines are used as a preservative and also occur naturally in wine.

To tell you more about what’s in the book, here is a series of questions answered by Dr. Galland:

Q: What have you discovered about the surprising hidden truths behind chronic symptoms?
A: You may not think of yourself as allergic. Your nose may not run, and your skin doesn’t itch. But you have common complaints that just won’t go away.
Do you suffer from:
•Weight gain?
•Depression or anxiety?
•Brain fog?

A hidden allergy is often the culprit. Chronic conditions that were previously diagnosed as autoimmune diseases, psychiatric disorders, or many others, wind up being allergic in origin.

Our search for answers to common mystery conditions, and the source of the allergy epidemic inspired us to write our new book, The Allergy Solution: Unlock the Surprising, Hidden Truth about Why You Are Sick and How to Get Well.

We reveal the proven role of allergy in causing weight gain, fatigue, headache, joint and muscle pain, a range of digestive symptoms from heartburn to diarrhea, mood problems, poor mental focus, and more. A step-by-step method for determining if you have hidden allergies is provided. And if you suffer from classic allergies like rhinitis, eczema or have asthma, our program addresses these issues from a nutritional and lifestyle perspective.

Q: Why are we seeing an epidemic of allergy today?
A: Allergies were once rare. Today they affect over a billion people. Environmental toxicity, depletion of beneficial intestinal bacteria and fast food all contribute to allergies.
Pollen counts are going up and up. A big cause? Air pollution, the kind generated by cars, buses and trucks. Scientists at the US Department of Agriculture investigated how air pollution affects ragweed. They discovered that pollution makes the plants grow twice as large and produce 5 times as much pollen. Many types of pollen, especially ragweed, are actually toxic. They contain an enzyme that damages the lining of your nose and lungs when you breathe them in. This sets the stage for rising allergies.

Driving While Allergic: Dutch scientists tested driving skills in people with allergies and discovered that Pollen exposure impaired the operation of an automobile to the same extent as drinking two cocktails.
Air fresheners increase the risk of allergies and asthma, mostly because of the chemical fragrances they contain, reports a study from the University of California. So what’s alternative? We can’t think of a better way to freshen your air than with ventilation. If the air outside your home is actually worse than the air inside, then try a commercial air purifier.

Cleaning sprays are also hazardous to your health. Using a household cleaning spray just once a week elevates your risk of developing asthma by 30 to 50 per cent, reports a study from Europe. But true clean doesn’t come from a cleaning spray. The Allergy Solution contains a program for freeing your home from these toxins. We call it Mission Detoxable. Step one is easy: ditch the chemical sprays and use water and baking soda for most cleaning jobs. Vinegar in water is great for glass and tile.
Q: How does nutrition impact allergies?
A: Research shows that people with allergies often suffer from nutritional deficiencies and may need nutritional enrichment of protective factors like selenium, magnesium, vitamins C and D, and omega-3 fats. In The Allergy Solution we provide a nutritional approach to overcoming allergy through food and supplements.
All of us need concentrated nutritional support for T-regs, which comes from natural folates found in vegetables such as leafy greens; carotenoids found in orange and yellow vegetables; the bioflavonoids found in things like parsley, strawberries and oolong tea; and detoxifying compounds found in broccoli.

Q: What are the most important nutritional factors for reversing allergy?
A: It is vital that the food you eat supply the nutrients you need to help your body remove toxins and establish healthy immune balance. To accomplish this, we include a simple program in The Allergy Solution called the Power Wash. It’s like hitting the re-set button on your computer. You can get started over a 3-day weekend.
With the Power Wash you eliminate the major problem foods like wheat, dairy, soy, corn, yeast, eggs and you nourish your body with a specially designed combination of vegetables, fruits, spices, herbs, and teas. They’ve been chosen because they support the function of a critical part of your immune system: regulatory T-lymphocytes. We call them T-regs. Their role is to turn off the unwanted immune reactions that create allergies. If you have allergies, you suffer from defective function of T-regs.
Q: How does allergy cause weight gain and prevent weight loss?
A: What happens is a vicious cycle driven by the effects of allergy on your metabolism. Clinical research reveals a strong link between allergy and weight gain. People with allergies are more likely to become overweight. People who are overweight are more likely to develop allergies.
Laboratory research shows that allergic reactions actually make fat cells grow larger and larger. Fat cells create a type of inflammation that unleashes stronger allergic reactions. Balancing immunity is essential for healthy weight loss.

Q: How does your program affect the skin?
A: Your skin is your most visible barrier against a toxic environment and a key target for allergic reactions. Allergy rapidly ages the skin and reversing allergy is essential to restoring its vitality.
The nutrients that nourish your immune cells are also essential for nourishing your skin. In addition, Mission Detoxable helps you decrease the stress placed on your skin by avoiding toxins in your home.

Q: What’s the role of your gut in creating or defending against allergy?
A: Two-thirds of your immune system is located in your intestinal tract. The gut is like a boot camp for training your immune cells. The drill sergeants are the bacteria living in your intestines. Biodiversity of these bacteria is essential for immune health and protects against allergy.
Antibiotics, pesticides, herbicides, disinfectants and the modern diet all destroy this diversity and contribute to the allergy epidemic. Our book contains a program for overcoming allergies by healing your gut. It’s called ARC, for Avoidance, Reflorastation and Cultivation.

Q: How does your book address the environmental challenges facing the world?
A: We wrote The Allergy Solution to change how the world thinks about allergy, health, and our relationship with the environment. We reveal the science that says allergies are not just annoying symptoms to be covered over by medications, and the environment is not just a convenient place to put our car exhaust, toss our garbage, and spray our pesticides. In the chapter “How Did We Get So Sick” we bring to light the astonishing research that connects pollution, global warming and toxins to rising allergies and asthma.

The environment is all around us and within us, inside our digestive tract, respiratory system, and whole body. we have exposed the truth that just as the earth’s environment is out of balance, our bodies have become out of balance. Now the environment we all depend on is threatened as never before.

Q: Can We Be Part of the Solution?
A: Absolutely. A community effort is needed to protect the environment and our health. Let’s all work together to turn around air pollution, giving those with asthma—and those without—a better chance to breathe free? Reductions in air pollution could also curb the rising levels of pollen, helping those with hay fever feel more comfortable. Using fewer toxic chemicals would reduce the burden on the environment.

Allergies are connected to the food we eat, the air we breathe, and the environment we live in. Join us and be part of the solution. Learn more about natural health by joining our community at Follow Dr. Galland on and Twitter (@leogallandmd), and follow Jonathan Galland at and on Twitter @JonathanGalland.

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Looking for health advice is one of the most common reason people search the web. Many websites provide health information and some even offer self-diagnosis using a symptom checker. After entering all of the symptoms the website suggests a possible diagnosis and advises to take some home remedies or see a doctor. A study recently mentioned on this blog showed that Wikipedia had errors in 9 out of 10 articles on different medical conditions.

Another recent study by Harvard researchers examined the accuracy of the sites that offer self-diagnosis. Not surprisingly, this study also found that the online programs are often wrong. The results were published in the British Medical Journal.

The lead author Ateev Mehrotra, commented that “These tools may be useful in patients who are trying to decide whether they should get to a doctor quickly, but in many cases, users should be cautious and not take the information they receive from online symptom checkers as gospel.”

Some of these symptom checkers were developed by prestigious institutions, including Harvard and other medical schools, major hospital groups, insurance companies, and some government agencies (including the United Kingdom’s National Health Service).

The researchers presented 45 hypothetical cases (including headaches) to test 23 different symptom checkers. Only 34% listed the correct diagnosis first and the correct diagnosis was in the top three possibilities in 51% of cases.

Dr. Mehrotra said that “It’s not nearly as important for a patient with fever, headache, stiff neck, and confusion to know whether they have meningitis or encephalitis as it is for them to know that they should get to an ER quickly.”

Of the 23 symptom checkers 58% provided correct advice and in more serious conditions, it correctly recommended emergency room visit in 80 percent of cases.

To complicate matters, the checkers with the most accurate diagnoses (Isabel, iTriage, Mayo Clinic, and Symcat) were not the ones that were best at recommending the appropriate level of care (, Steps2Care, and Symptify).

The researchers compared the online symptom checkers with a live telephone triage nurse offered by many insurance companies. The accuracy of live nurses is between 61% and 69%, so these are more accurate accurate, but also leave a lot of room for improvement. Hopefully, these online programs will continue to evolve, but at this point, you should not rely on them.

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The Food and Drug Administration (FDA) has just released a new strengthened warning about NSAIDs. Prescription and over-the-counter NSAIDs (ibuprofen, naproxen, nabumetone, diclofenac, and other) are widely used for the treatment of pain including different types of headaches. They are fairly safe, especially in young healthy people who take NSAIDs for an occasional headache. However, the risk of strokes and heart attacks and heart failure is higher in older people, especially those with risk factors such as smoking, diabetes, hypertension, high cholesterol, and other. These risks are present with all NSAIDs, except for aspirin, which in fact can sometimes lower these risks. So, when in doubt, take aspirin, which is the main ingredient of my product, Migralex. Migralex is fast acting and is less likely to upset your stomach because of the buffering effect of magnesium. You can buy Migralex on,, and CVS stores.

Here is the full text of FDA’s announcement:

Safety Announcement
The U.S. Food and Drug Administration (FDA) is strengthening an existing label warning that non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) increase the chance of a heart attack or stroke. Based on our comprehensive review of new safety information, we are requiring updates to the drug labels of all prescription NSAIDs. As is the case with current prescription NSAID labels, the Drug Facts labels of over-the-counter (OTC) non-aspirin NSAIDs already contain information on heart attack and stroke risk. We will also request updates to the OTC non-aspirin NSAID Drug Facts labels.
Patients taking NSAIDs should seek medical attention immediately if they experience symptoms such as chest pain, shortness of breath or trouble breathing, weakness in one part or side of their body, or slurred speech.

NSAIDs are widely used to treat pain and fever from many different long- and short-term medical conditions such as arthritis, menstrual cramps, headaches, colds, and the flu. NSAIDs are available by prescription and OTC. Examples of NSAIDs include ibuprofen, naproxen, diclofenac, and celecoxib (see Table 1 for a list of NSAIDs).

The risk of heart attack and stroke with NSAIDs, either of which can lead to death, was first described in 2005 in the Boxed Warning and Warnings and Precautions sections of the prescription drug labels. Since then, we have reviewed a variety of new safety information on prescription and OTC NSAIDs, including observational studies,1 a large combined analysis of clinical trials,2 and other scientific publications.1 These studies were also discussed at a joint meeting of the Arthritis Advisory Committee and Drug Safety and Risk Management Advisory Committee held on February 10-11, 2014.

Based on our review and the advisory committees’ recommendations, the prescription NSAID labels will be revised to reflect the following information:

The risk of heart attack or stroke can occur as early as the first weeks of using an NSAID. The risk may increase with longer use of the NSAID.
The risk appears greater at higher doses.
It was previously thought that all NSAIDs may have a similar risk. Newer information makes it less clear that the risk for heart attack or stroke is similar for all NSAIDs; however, this newer information is not sufficient for us to determine that the risk of any particular NSAID is definitely higher or lower than that of any other particular NSAID.
NSAIDs can increase the risk of heart attack or stroke in patients with or without heart disease or risk factors for heart disease. A large number of studies support this finding, with varying estimates of how much the risk is increased, depending on the drugs and the doses studied.
In general, patients with heart disease or risk factors for it have a greater likelihood of heart attack or stroke following NSAID use than patients without these risk factors because they have a higher risk at baseline.
Patients treated with NSAIDs following a first heart attack were more likely to die in the first year after the heart attack compared to patients who were not treated with NSAIDs after their first heart attack.
There is an increased risk of heart failure with NSAID use.
We will request similar updates to the existing heart attack and stroke risk information in the Drug Facts labels of OTC non-aspirin NSAIDs.
In addition, the format and language contained throughout the labels of prescription NSAIDs will be updated to reflect the newest information available about the NSAID class.

Patients and health care professionals should remain alert for heart-related side effects the entire time that NSAIDs are being taken.

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Germany was just voted world’s favorite country, according to a report in the USA Today. It also may be the most advanced country in the area of medical rehabilitation. I just came back from Germany where I was invited to give lectures at two prominent clinics. Doctors from both institutions had visited our New York Headache Center to learn about our approach to the treatment of migraines and to learn Botox injection techniques.

My first stop was at the Berolina Klinik, a 280-bed rehabilitation hospital located 80 miles west of Hanover. This hospital provides rehabilitation for a variety of conditions, including orthopedic problems, depression, and chronic headaches. Patients are admitted for a period of 4 to 5 weeks. Treatments available at this institution include physical therapy, biofeedback, individual and group psychotherapy, art therapy, and other. All patient rooms are private. There is a 25-meter (82 feet) swimming pool, gym, inviting dining rooms (with excellent food – I sampled it), green lawns with reclining chairs, and all of it immaculately clean and well-maintained. Staying in such a facility for 4 to 5 weeks is a luxury not available to most Americans. The hospital welcomes patients from abroad and the cost is surprisingly low – about $9,000 for a month of stay, which is less than a third of the cost in the US. They will even pick you up at the Frankfurt airport (third busiest in Europe), which is only 3 hours’ drive. Most of the German patients treated at the Berolina Klinik are covered by insurance, mostly by the German pension fund. The pension fund annually evaluates every facility using strict outcome measures, including the percentage of patients employed two years after being treated at a rehabilitation facility. Berolina Klinik consistently rates among the top German rehabilitation clinics. Dr. Zoltan Medgyessy is the main headache specialist at the clinic and is considered to be one of the leading headache experts in Germany.

The second stop was in Kiel at one of the best German headache and pain clinics, Schmerzklinik Kiel, which is directed by Dr. Hartmut Göbel. This clinic is also an in-patient facility (unlike in the US, where the word clinic implies an office setting). Approximately 70% of patients treated at the Schmerzklinik suffer from headaches and 30% from chronic pain. The clinic is housed in a beautiful building located on the Kiel fjord. Dr. Göbel is one of the top headache researchers and he and I have collaborated on the study of butterbur for the treatment of migraines, which was published in 2004. On this trip I had the honor of speaking in Dr. Göbel’s Master Class – an annual training course for German headache specialists. While I would refer patients who need longer-term rehabilitation (or detox from opioid and other headache drugs) to the Berolina Klinik, Schmerzklinik is where I refer European patients with complicated headache problems and those needing shorter hospital stays.

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Don’t use Wikipedia for medical information and tell your doctor not to either. It is the most popular reference site not only for the lay public, but also for doctors – anywhere from 47% to 70% of physicians and medical students admit to using it as a reference.

A study just published in a medical journal shows that Wikipedia very often offers erroneous information.The researchers looked at articles on 10 common conditions: coronary artery disease, lung cancer, major depression, concussion, osteoarthritis, chronic obstructive lung disease, hypertension,diabetes, back pain, and hyperlipidemia.

Articles on each condition were evaluated independently by two physicians to make sure that the evaluations were not biased and were consistent between two doctors. The information on Wikipedia was compared to the up-to-date information on these diseases published in scientific medical journals. Shockingly, only information on concussion was accurate, while information on the other nine conditions contained serious errors. This study did not include migraines or other headaches, but it is very likely that at least some information on these conditions are also incorrect.

Tell your doctor about this study, just to make sure that he or she knows about it. For consumers, the best sources of information are,, and

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There is no debate about the fact that there is an epidemic of vitamin D deficiency in the United States – it affects about two thirds of the population. However, it is bewildering why scientists are still debating if people should be taking vitamin D supplements. You would think that this is a pretty obvious, common sense conclusion. But common sense is far from common, especially in academia (and obviously not just in medicine – it is much worse in the “soft” social sciences).

Two major studies published in the highly respected British Medical Journal reviewed studies that involved data on more than a million people. Both studies showed that vitamin D provided significant benefits. Vitamin D appears to protect against major diseases. Adults with lower levels of vitamin D had a 35% increased risk of dying from heart disease,14% greater risk of dying from cancer, and a higher risk of dying from any cause. Taking vitamin D reduced the risk of dying from all causes by 11%. The authors estimate that 13% of all deaths in the US are due to low vitamin D levels. This is an astonishing discovery, on the par with the discovery that aspirin dramatically reduces the risk of different types of cancer.

So, a reasonable person would expect the medical community to begin recommending vitamin D supplementation, at least for those with low levels. But here is what one of the authors said:: “Based on what we found, we cannot recommend widespread supplementation”. He called for more clinical trials to prove beyond any doubt that taking vitamin D is a good idea. These trials usually cost many millions of dollars and take many years to complete. How much does it cost to take 2,000 units of vitamin D3 daily? One dollar a month. And what are the potential side effects of taking 2,000 units of vitamin D? None.

The bottom line is, if your vitamin D level is below 40, take 2,000 units a day. Some people may need higher doses if their levels remain low, which is not unusual. The normal range is considered to be between 30 and 100, but there are studies indicating that you are safer with a higher level. One such study showed that attacks of multiple sclerosis are less likely if you have high normal rather than low normal levels. We do not know if taking vitamin D prevents migraines and other types of headaches (such a study does need to be done), but we do recommend to everyone whose vitamin D level is low to get it up to normal range.

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Botox is the most effective preventive treatment for chronic migraine headaches. It is also the only treatment approved by the FDA for this condition, which affects 3 to 4 million Americans.

Despite the wide use of Botox for cosmetic indications, many people still have unfounded fears of this procedure. Some are afraid of the fact that it is a toxin and indeed, in large amounts it is deadly. However, acetaminophen (Tylenol) kills over 500 people every year, which is significantly more than all the deaths from Botox given to millions of people in over the 25 years that Botox has been on the market. There has been no deaths reported when Botox was used for headaches or cosmetic reasons. Botox is not free of side effects, but they tend to be mild and transient.

Another fear is that the procedure is painful and very unpleasant. I recorded this video of me injecting one of my patients (with her permission) so that you can see what the procedure looks like. It took me 3 minutes and 41 seconds from start to finish and, as you can see, with little discomfort.

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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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Children suffering from migraine headaches are more likely to have difficulty performing well in school, according to a new report published in Neurology. The doctors studied 5,671 children between ages 5 and 12 from 87 Brazilian cities and found that episodic migraine was present in 9% of children (9.6% of girls and 8.4% of boys), probable migraine, in 17.6% (17.3% of girls and 17.8% of boys) while chronic migraine in 0.6% (equally in boys and girls). Headaches were more common between ages 9 and 12 than 5 to 9. Chronic migraine was more common in poor children. Poor performance at school was significantly more likely in children with migraine and chronic migraine, compared to probable migraine and tension-type headaches.
These are not very surprising results, although they cannot be generalized to all children with migraines. It is very common for me to see children who do exceptionally well in school despite having many migraine attacks and missing many days of school. It is possible that those hard-working and driven kids get headaches because of stress, but despite their severe headaches are able to perform well. Because they are high achievers and like doing everything well, they often excel at biofeedback, which helps them learn how to control their stress and reduce their headaches. Regular meals, exercise, and sleep are also very important. We try magnesium, COQ10 and other supplements next, and if headaches are very frequent, Botox injections followed by preventive medications.

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

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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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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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New risks of Prilosec (omeprazole), Nexium, and other similar drugs (so-called proton-pump inhibitors, or PPIs) are being highlighted by the FDA. They can increase the risk of Clostridium difficile-associated diarrhea, a serious infection. This probably occurs because lowering stomach’s acidity allows this bacterium grow more easily. In additional to watery diarrhea, this sinfection causes abdominal pain, and fever, especially after recent antibiotic use. This as another reason to try to limit the use of PPIs. Their use is also associated with a small increase in the risk of pneumonia, bone fractures, vitamin B12 deficiency, and magnesium deficiency. Having diarrhea from a bowel infection will worsen these deficiencies. It is not easy to stop a PPI because heartburn and other symptoms will first get worse, due to “rebound” increase in acidity. This is why once you start taking a drug like Prilosec, it is very difficult to stop. The way to do it is to first lower the dose, then extend the dosing interval to every other day, every third day, etc. Temporarily taking an H2-blocker (Zantac, Pepcid) and antacids can also help in getting off PPIs. PPIs include Prilosec, Prevacid, Protonix, Nexium, Dexilant, and Aciphex.
What does this have to do with headaches? PPIs can sometimes cause headaches directly, but more often they worsen migraines by interfering with the absorption of magnesium and other vitamins. This is a class effect, so switching from one drug to another will not help. Taking a magnesium, vitamin B12 and other supplements may help, but many of my patients, especially those who cannot stop the PPI medication require an intravenous infusion of magnesium and an injections of vitamin B12.

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Migraines are often mistaken for sinus infections, and are treated with antibiotics. The reson for this confusion is that migraines can cause pain in the area of sinuses and some people will even have a clear discharge from their nose during a migraine attack. Sinus infection is really easy to diagnose – it usually causes a yellow or green discharge from the nose. But even if you do have a true sinus infections antibiotics are usually unnecessary because the infection is caused by a virus and viral infections do not respond to antibiotics. This well-know fact is confirmed in a new study which was just published in the Journal of the American Medical Association. The study involved 166 adults with a sinus infection who were given either a placebo or an antibiotic for 10 days. There was no difference between the two groups in the satisfaction with the treatment, the amount of time missed from work, and every other parameter measured. The authors (doctors at Washington University in St. Louis) do recommend starting antibiotics if the condition does not after 5 – 7 days.

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We are conducting a trial of a very novel treatment for migraine headaches. ElectroCore is a company that developed a small hand-held device which is placed at the front of the neck during a migraine and which painlessly stimulates the vagus nerve. The idea for this device came from my study of 6 patients who had a vagus nerve stimulator implanted in the neck. The results of this study was published in 2005 in the journal Cephalalgia. All six patients had very debilitating headache which did not respond to dozens of drugs, Botox injections, nerve blocks, acupuncture and a variety of other treatments. Two of them had cluster headaches and both improved. Four had chronic migraines and two of these also improved.
Implanting a device to stimulate the vagus nerve is an invasive and expensive procedure, so having a small portable and non-invasive device offers great advantages. This device is approved in Europe and id currently in clinical trials in the US.

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Merck discontinued the development of telcagepant, a promising new drug which represents a new class of migraine drugs, so-called CGRP antagonists. These drugs appear to be as effective as sumatriptan (Imitrex) and other triptans in aborting a migraine attack, but do not carry an increased risk of strokes and heart attacks which can occur, albeit very rarely, with triptans. Telcagepant was also tested as a daily preventive drug for migraines and in those trials some patients developed minor liver abnormalities. At first, Merck continued to pursue the development of telcagepant for abortive treatment, but recently decided that the risk of not getting it approved by the FDA because of the liver problems was to high. This again demonstrates that part of the reason why new drugs are so expensive – for every one that makes it to the market there are many that after an investment of hundreds of millions of dollars do not. It is likely that Merck and other companies will continue to do research to find a CGRP antagonist without serious side effects.

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Many, but not all epilepsy drugs are also effective in preventing migraine headaches.   For example, divalproex sodium (Depakote), topiramate (Topamax), and to a lesser degree gabapentin (Neurontin), pregabalin (Lyrica), and levetiracetam (Keppra) relieve migraine headaches, while other epilepsy drugs, such as phenytoin (Dilantin) and carbamazepine (Tegretol)  do not.  A report by Drs. Krusz at the annual meeting of the American Headache Society held last month suggests that a new epilepsy drug, lacosamide (Vimpat) may also be effective for the treatment of headaches.  Dr. Krusz treated 22 patients with chronic migraines  (patients who had more than 15 headache days each month) with this medication and discovered that on average the monthly number of headaches dropped from 21 to 13.  Side effects, such as drowsiness, nausea, and cognitive impairment lead 4 patients to stop the drug.  Despite very impressive results it is premature to declare lacosamide an effective headache treatment because the study was very small and not placebo-controlled.

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We always try to use one preventive drug or Botox for the treatment of frequent or very severe migraine headaches.  However, it is not unusual to go through several drugs and not find one which works well and does not cause side effects.  Under those circumstances combining two drugs or Botox injections with a daily drug with is the next step.  A study to be presented at the 62nd annual meeting of the American Academy of Neurology looked at 92 migraine patients who did not respond to a single drug.  86 of these patients found relief from a combination of either topiramate (Topamax) with verapamil (Calan, Verelan), or amitriptyline (Elavil) and a beta blocker (such as Inderal or propranolol, or atenolol).  Combining two medications makes sense is they have different mechanism of action.  For example topiramate is an epilepsy drug, while verapamil is a blood pressure medicine in the category of calcium channel blockers.  Amitriptyline is an antidepressant with pain-relieving properties, while beta-blockers are blood pressure drugs.  At times we combine two epilepsy drugs or two anti-depressants if they work in two distinct ways.

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Many migraine sufferers complain of dizziness, fatigue, exercise intolerance, blurred or tunnel vision, diminished concentration, tremulousness, nausea and recurrent syncope (fainting).  These symptoms are often attributed to anxiety or panic attacks.  A study to be presented later this month by Dr. Mark Stillman of Cleveland Clinic at the 62nd annual meeting of the American Academy of Neurology in Toronto reveals that the true cause of these symptoms in many migraine patients is POTS.  Postural tachycardia syndrome, or POTS is a pronounced increase in heart rate (by at least 30 beats per minute) on standing up.  Most of these patients do not suffer from a more familiar condition, orthostatic hypotension, which is a drop in blood pressure on sanding up.  Treatment of POTS is difficult and usually involves increasing salt and water intake, aerobic exercise, and small doses of beta blockers (a type of blood pressure medicine also used for prevention of migraines).

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Alcohol can trigger a headache immediately or soon after it is consumed or the next morning.   Some people develop a headache only from a particular type of alcohol, such as red wine, rum, or beer, while others cannot drink any form of alcohol without getting a headache.  It seems that vodka is least likely to cause a headache, because it is possible that it is not alcohol that is causing headaches, but rather preservatives, such as sulfites, fermentation products, and natural colors.  Some people are exquisitely sensitive – a small sip of wine can trigger a headache within minutes, and some can drink two glasses of wine without a headache, while the third glass will always result in a headache.  If you’ve found a medicine that works for your headaches, have it handy since the sooner you take it the better it will work.  However, check with your doctor to see if your medicine can be taken with alcohol (none of them should be mixed with alcohol, but some are more dangerous than other).  Headaches that occur the day after drinking are usually due to overindulgence and are thought to be in part due to dehydration and in part due to magnesium depletion by alcohol.

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Migralex is finally available to all headache sufferers.  This is the first new brand of headache medicine in 15 years.  After years of painstaking research, complicated development work, and manufacturing setup it is very gratifying to see Migralex available at and independent pharmacies.  If you know someone who suffers from headaches, please tell them about Dr. Mauskop’s Migralex.  Migralex works quickly, has few side effects, and works for many different types of headaches.  Please go to for more information.

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Headache Relief is a new iPhone app which I developed to help patients better manage their headaches.  The main feature of the app is a headache diary.  A summary of all your diary entries can be emailed to yourself or your doctor in an Excel spreadsheet form.  I find that patients who keep a diary benefit from it in many ways.  The diary makes it easier to figure out what may be causing your headaches, how well the treatment works, and allows you to better control your headaches.  The potential triggers that are recorded in the diary include stress, menstrual cycle, food, sleep, and other.  Weather can be a major contributor and the three most common weather-related triggers are temperature, humidity and barometric pressure.  A unique (and very neat) feature of this app is that if you to enter your zip code these three weather parameters will be downloaded into your diary.  The app also contains an e-book with a wealth of information on headaches, natural and pharmacological therapies.  And the price is right – it’s free.  Please let me know what you think or better still, post your evaluations on the iTunes store.

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Needle-free injection of sumatriptan (Imitrex) was tested for its ease of use and for its bioequivalence in a study led by Dr. Jan Brandes.  The new device that provides needle-free subcutaneous injections was easy to use and if injected into the thigh or abdomen (but not the upper arm) delivered the same amount of medicine as an injection with a needle.  Unfortunately, needle-free does not mean pain-free, so the injection still hurts.  This device, when it is approved by the FDA, may be useful for those patients who are afraid of needles.  Many migraine sufferers still do not know that injections of sumatriptan can be easily self-administered using a pen-like device that does contain a needle.  Many doctors do not offer this option because they do not think that patients will readily accept an injection or because they don’t realize how severe the migraines are.  I see many migraine sufferers who gladly take an injection over the tablet.  It is particularly effective for people who have severe nausea and vomiting with their migraine.  The speed of relief is another reason to take an injection – some patients wake up with a migraine and have to go to work or take care of their children and cannot wait for 1-2 hours before the tablet provides relief.  I have taken sumatriptan injection many times myself.  Usually the tablet works for me, but if before going to bed I have a headache from the wine I had with dinner, I will often opt for a shot.  The shot works within 10-15 minutes and allows me to fall asleep right after that, while a tablet may take an hour or longer.

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A new treatment for migraines is very effective and well tolerated, according to a paper published in Neurology.  Two years ago I mentioned on this blog that this new migraine drug did well in Phase II trial and now the results of Phase III also appear to be very positive.   The study was double-blind and placebo-controlled and involved more than 1,200 patients.  The drug’s chemical name is telcagepant and it belongs to a new family of migraine drugs, CGRP antagonists.   They work on a different receptor than the triptans (sumatriptan or Imitrex and similar drugs) and appear to be as effective.  Possible advantages of this drug are that it may work when triptans are ineffective and it does not appear to constrict coronary blood vessels, which can happen, albeit rarely, with triptans.

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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 will cause unnecessary anxiety to millions of pregnant women. 

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

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Doxycycline has been reported to relieve treatment-resistant new daily persistent headache in four patients.  The dose was 100 mg twice a day and was given for 3 months.  One of the patients responded after two weeks, but the average response time was 2 months.  The lead author of the study, Dr. Todd Rozen speculated that the reason for improvement is the fact that doxycycline is not only an antimicrobial drug, but also acts as an anti-inflammatory agent.

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Mindfulness meditation has been shown to produce numerous benefits in older adults with chronic low back pain.  These benefits included less pain, improved attention, better sleep, enhanced well-being, and improved quality of life.  One patient reported: “I felt like a new person”.  The subjects attended a weekly 90-minute class and practiced for 45 minutes every day for 8 weeks.  The study was conducted at the University of Pittsburgh by Natalia Morone and her colleagues, who speculated that this approach might help with other chronic conditions.  And we can speculate that if the elderly, who are often regarded to have a less adaptable nervous system,  responded so well, then younger patients may do even better.

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Chronic migraine is very disabling and is poorly treated according to a study by Dr. Marcelo Bigal and his colleagues published in the current issue of journal Neurology.  The study looked at 520 patients with chronic migraine (those who had more than 15 days with headaches a month) and 9,424 with episodic.  More than half of the patients with chronic migraines missed at least five days of household work, compared 24% of patients with episodic migraine.  The majority of chronic migraine sufferers (88%) had previously soguht care, but most of them did not receive specific acute or preventive medications.  Only 33% of these patients were on preventive medications at the time of the study.  Millions of Americans who suffer from migraines do not receive appropriate treatment, but those with chronic migraines are particularly under-treated and suffer needlessly. 

Chronic migraine is a common conditions

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Migralex is an over-the-counter medication for the treatment of headaches, which will become available in November of 2009.  Results of the first study of Migralex were presented at the annual scientific meeting of the American Headache Society in Boston.  In an open-label study 50 patients with headaches who were being treated at the NYHC compared Migralex with their usual medication.  Half of the patients found Migralex better or much better than their usual treatment and 27 were willing to take it again.  In 31 of 50 patients the usual medication was a triptan ( a prescription migraine medication) and in 19 it was a prescription or over-the-counter pain medication.  Migralex was well tolerated, with only one patient reporting upset stomach.

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A person  empathizing with someone in pain perceives his or her own pain as more severe and unpleasant.  Researchers at McGill University published these findings in the current issue of journal Pain.  This observation could explain, at least in part, high frequency of pain symptoms observed in spouses of chronic pain patients.   Even laboratory mice have heightened pain behavior when exposed to cagemates, but not to strangers, in pain.  Clearly, the thing to do is not to ignore your spouse’s or friend’s pain, but rather try to get the pain relieved.  If that is not possible, hopefully, a cognitive-behavioral psychologist may be able to devise a way to be very supportive and helpful without constantly feeling badly for the person in pain.

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Treatment of migraines leaves a lot to be desired and in part not because we do not have effective treatment, but because of a communication barrier.  Doctors appear not to want to hear what migraine patients have to say about their headaches, according to a remarkable study by a top headache researcher Richard Lipton and his colleagues.  Patients and doctors agreed to be videotaped during a visit and 60 such interactions were analyzed.  The analysis showed that doctors did not ask about the disability of headaches and tended to ask closed-end short questions.  Very often the information they did obtain was incorrect.  55% of doctor-patient pairs were misaligned regarding frequency of attacks; 51% on the degree of impairment. Of the 20 (33%) patients who were preventive medication candidates, 80% did not receive it and 50% of their visits lacked discussion of prevention.  The authors recommended that doctors assess impairment using open-ended questions in combination with what is called the ask-tell-ask technique.  

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“Anne Frank’s headache” is the title of an article just published by RF de Almeida and PA Kowacs in the journal Cephalalgia.  This is an abstract of the article: “There are a significant number of famous people who suffered from frequent headaches during their lifetime while also exerting an influence of some kind on politics or the course of history. One such person was Anneliese Marie Frank, the German-born Jewish teenager better known as Anne Frank, who was forced into hiding during World War II. When she turned 13, she received a diary as a present, named it ‘Kitty’ and started to record her experiences and feelings. She kept the diary during her period in hiding, describing her daily life, including the feeling of isolation, her fear of being discovered, her admiration for her father and her opinion about women’s role in society, as well as the discovery of her own sexuality. She sometimes reported a headache that disturbed her tremendously. The ‘bad’ to ‘terrifying’ and ‘pounding’ headache attacks, which were accompanied by vomiting and during which she felt like screaming to be left alone, matched the International Headache Society criteria for probable migraine, whereas the ‘more frequent headaches’ described by Anne’s father are more likely to have been tension-type headaches than headaches secondary to ocular or other disorders.”

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Migralex – A Breakthrough in the Treatment of Headaches.

Migralex is a headache medication developed and patented by Dr. Alexander Mauskop, Director and Founder of the New York Headache Center. Migralex is a product of 15 years of research and development. It will become available for purchase at the end of 2009 at and

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“Old Drugs In, New Ones Out”, a story in the New York Times on July 1, 2007 reports on a growing trend in the pharmaceutical industry where two existing generic drugs are combined into a new more effective product. “Old Drugs In, New Ones Out”, a story in the New York Times on July 1, 2007 reports on a growing trend in the pharmaceutical industry where two existing generic drugs are combined into a new more effective product. One example is Trexima, a drug developed by Pozen and GlaxoSmithKline, which contains sumatriptan (Imitrex) and naproxen (Aleve). Combining drugs with different mechanisms of action results in an improved efficacy, although side effects could also add up. The New York Headache Center has participated in the trials of Trexima, which is expected to be approved by the FDA in August of this year.

Another example of combining two old ingredients is Migralex, a medication for the acute treatment of headaches, which is being developed by Dr. Alexander Mauskop. Migralex is expected to be available to patients by the end of 2009. It will contain a combination of aspirin and magnesium.  Migralex will have an improved side effect profile because magnesium has a protective effect on the stomach lining.

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