Headache NewsBlog

Transcranial Magnetic Stimulation for Pain

By: Dr. Mauskop

21-05-2025

Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Headaches in children, Migraine, neurostimulation, Pain

We have been using repetitive transcranial magnetic stimulation (rTMS) to treat chronic migraine headaches and other types of pain and neurological disorders. An article published in Pain Medicine News provides a brief review of the use of rTMS in treating painful conditions. rTMS has been reported to relieve neuropathic pain, orofacial pain, phantom pain, low back pain, myofascial pain syndrome, pelvic pain, and complex regional pain syndrome.

A recent study published in the journal Pain suggests that chronic low back pain may be related to the dysfunction in the periaqueductal gray (PAG), a brain region involved in pain regulation. This finding highlights the potential for brain-targeted therapies such as TMS.

rTMS is a non-invasive treatment, and it might help reduce pain by modulating brain regions involved in pain processing. Although more studies are needed, rTMS could offer a drug-free option for those with persistent low back pain.

rTMS of the brain is approved by the FDA to treat anxiety, depression, OCD, and nicotine addiction. rTMS is also approved to treat peripheral pain by applying rTMS to the area of pain. This involves using a magnetic coil on an arthritic joint, an area of back pain, or any other body part.

Getting an FDA approval for chronic migraines or other painful conditions is a lengthy and expensive process. For-profit companies will not invest millions of dollars in this project since rTMS treatment is difficult to patent. The funding will need to come from the NIH or non-profit foundations. We do need FDA approval in order to have insurance companies to pay for this treatment.

Breakthrough in Treating Posttraumatic Headache with TMS

By: Dr. Mauskop

08-05-2025

Alternative Therapies, Brain disorders, Chronic migraine, Head trauma, Headaches, Headaches in children, neurostimulation, New treatments, post-traumatic headache

At the New York Headache Center, we have been using fMRI-guided repetitive Transcranial Magnetic Stimulation (rTMS) to treat chronic migraine, posttraumatic headaches (PTH), pain syndromes, and neurological disorders. This approach uses functional MRI (fMRI) to precisely target brain regions involved in pain and mood regulation, enhancing treatment outcomes. A recent study published in The Journal of Neuropsychiatry and Clinical Neurosciences (JNCN Study) by researchers at Kaizen Brain Center in La Jolla, California, provides compelling evidence supporting this method in the treatment of PTH following traumatic brain injury (TBI). The study compared standard rTMS to fMRI-guided TMS, showing data on headache symptom improvement that aligns with our clinical experience.

PTH is the most common chronic symptom following mild-to-moderate TBI, often accompanied by depression and anxiety, which severely impact quality of life. Currently, there are no FDA-approved pharmacological treatments specifically for PTH. rTMS is a non-invasive technique that is FDA-approved for the treatment of anxiety and depression. For these indications, rTMS is directed at the left dorsolateral prefrontal cortex (DLPFC). The researchers treated PTH patients with rTMS also targeting DLPFC region. However, DLPFC is a fairly large area and the fMRI can help find a more specific region within left DLPFC that has the most anomalous connections to the rest of the brain.

In the discovery phase, 21 patients with PTH and depression received standard rTMS. While significant improvements were observed in depression and anxiety, the functional impact of headache (FH) did not significantly decrease, though over half reported reduced headache severity or frequency. Here, fMRI was critical in some patients, enabling individualized network-based targeting by analyzing resting-state brain connectivity. This helped identify specific neural networks, like the default mode or dorsal attention networks, tailored to patients’ symptoms, such as depression with anxiety or anhedonia. An exploratory analysis using normative fMRI data from a human connectome database further pinpointed a DLPFC coordinate (-26, 36, 42) where increased functional connectivity correlated with better headache outcomes.

In the translational phase, seven patients were treated at this precise coordinate, guided by the fMRI-derived insights from the discovery phase. They experienced significant reductions in FH (16% decrease) after four weeks, alongside faster improvements in depression and anxiety within one to two weeks. The use of fMRI to map brain networks and refine targeting likely contributed to the enhanced outcomes compared to the earlier phase, suggesting a potential dual-benefit treatment for PTH and mood disorders.

Despite limitations like a small sample size and the need for randomized controlled trials, these findings highlight rTMS, enhanced by fMRI-guided targeting, as a promising tool for PTH management. The protocol used in this study is different from what we do in our practice. Without fMRI data, we usually stimulate at least three areas – DLPFC, as well as bilateral motor or occipital cortex. fMRI often suggests other regions as well. It is possible that stimulating more than one area may yield better results. Other variables that have not been worked out yet are the frequency of treatments needed (we find that once a week often is sufficient) and stimulation parameters – high frequency vs low frequency and vs theta-burst stimulation.

New Study: Over-the-Counter Pain Relievers Speed Up Concussion Recovery

By: Dr. Mauskop

03-05-2025

Brain disorders, Chronic migraine, Head trauma, Headache medications, Headaches, Headaches in children, Migraine, post-traumatic headache

A major new study offers hope for athletes and others recovering from concussion: using over-the-counter (OTC) analgesics like acetaminophen and NSAIDs may significantly improve symptoms and reduce recovery time.

Researchers from the University of Washington Medical Center, working with NCAA athletes and military cadets, tracked over 1,600 young adults who experienced a concussion. They compared those who took OTC pain relievers after their injury to those who did not.

Faster Recovery: Athletes who used OTC analgesics reached 90% recovery about 7 days sooner than those who didn’t take any pain relievers.

Quicker Symptom Relief: Those taking OTC medications were cleared for unrestricted return to play faster and became asymptomatic sooner.

Lower Symptom Severity: Participants reported significantly less severe symptoms and headaches after taking OTC analgesics.

Timing Matters: Taking pain relievers within the first 24 hours after injury was especially effective, likely because early intervention targets the initial wave of inflammation following concussion.

Surprisingly, the study found no significant difference between the types of OTC pain relievers, acetaminophen and NSAIDs (like ibuprofen), both provided similar benefits for concussion recovery. This suggests that simply managing pain early on, regardless of the specific medication, can help speed up recovery.

Some of my colleagues feel that taking pain relievers or even migraine medications can delay the recovery. This study suggests that OTC pain relievers soon after a concussion may help reduce symptoms and speed recovery. Most headaches that occur after a concussion are migrainous in type and also respond to migraine drugs such as sumatriptan, rimegepant, and others. These headaches also respond to Botox injections, just like migraines.

Flossing teeth: a surprising link to fewer strokes and migraines

By: Dr. Mauskop

20-04-2025

Alternative Therapies, Brain disorders, Chronic migraine, Migraine, Science of Migraine

You may think of flossing as a way to keep your teeth and gums healthy, but new research shows that it may also protect your heart and brain. Recent scientific studies reveal compelling connections between gum health, stroke risk, and chronic migraines.

A major study led by Dr. Souvik Sen at the University of South Carolina found that flossing at least once a week can cut your risk of ischemic stroke by 22% and cardioembolic stroke by 44%. Flossing also lowers the risk of atrial fibrillation, a heart rhythm problem that raises stroke risk. These benefits are similar to those of aspirin but without the side effects of increased bleeding and stomach ulcers. The reason may be that flossing reduces gum disease and oral inflammation, which are linked to heart and blood vessel problems.

Two recent reviews have highlighted that people with gum disease (periodontitis) are more likely to suffer from migraines. One large observational study found that those with periodontitis had a 29% higher risk of migraines, and the worse the gum disease, the higher the risk. A systematic review of eight studies confirmed this link, pointing to inflammatory markers, like CGRP and PTX3, that are elevated in both conditions. Chronic inflammation from gum disease may trigger or worsen migraine attacks.

Flossing is a simple, affordable way to lower your risk of stroke and potentially reduce migraine frequency. By keeping your gums healthy, you’re also helping to protect your heart and brain.

Answer from Perplexity: pplx.ai/share

fMRI changes in kids after a concussion; could TMS help?

By: Dr. Mauskop

13-04-2025

Brain disorders, Chronic migraine, Head trauma, Migraine, neurostimulation, New treatments, post-traumatic headache

Concussions in children are far more than just a bump on the head—they can trigger subtle yet significant changes in brain function that may linger long after the visible symptoms fade. A recent prospective, longitudinal study sheds new light on how pediatric concussion disrupts functional brain network connectivity over time.

In this large-scale study, researchers tracked 385 children with concussion and 198 with mild orthopedic injuries (used as a control group) across five pediatric hospitals in Canada. Each child underwent high-resolution fMRI scans shortly after injury and again at either three or six months. The focus was on resting-state functional connectivity (FC)—how different regions of the brain communicate when the brain is not engaged in a specific task.

While within-network connectivity remained largely intact, disruptions in between-network connectivity emerged over time in the concussion group. Key findings included:

– Reduced connectivity between the visual and ventral attention networks across all time points after concussion.

– Lower connectivity between the visual and default mode networks, specifically at six months post-injury.

– Age-dependent differences in connectivity between the frontoparietal and ventral attention networks at three months: younger children showed reduced connectivity, while older children showed increased connectivity.

– Sex- and symptom-related differences in attention network connectivity, with girls without persisting symptoms showing higher connectivity between dorsal and ventral attention networks than those with lingering symptoms.

These findings point to long-term changes in how different brain networks interact after pediatric concussion, even after most children appear clinically recovered. It suggests that functional connectivity may be a sensitive biomarker of lasting brain changes—possibly outlasting observable symptoms.

This study provides crucial evidence that brain network changes can persist for months after a concussion, particularly between regions responsible for attention, vision, and executive function. These disruptions are influenced by age, sex, and whether or not symptoms persist, highlighting the complexity of brain recovery in children.

The authors did not discuss potential therapies, but transcranial magnetic stimulation (TMS) is a potential treatment that could normalize the disrupted networks. It is a non-invasive neuromodulation technique that uses magnetic pulses to stimulate specific brain regions. Already FDA-approved for conditions like depression and anxiety in adults, TMS is gaining interest for its potential in treating brain network dysfunctions after a concussion and other neurological disorders. We use it primarily for refractory chronic migraines but also persistent post-concussion symptoms.

Zonisamide Shows Promise as a Preventive Migraine Treatment for Kids and Teens

By: Dr. Mauskop

05-04-2025

Chronic migraine, Headache medications, Headaches, Headaches in children, Migraine, Science of Migraine

A new study suggests that zonisamide (Zonegran), a medication traditionally used to treat seizures, may help reduce migraine days in children and teens.

The research, led by Dr. Anisa Kelley of Northwestern University Feinberg School of Medicine, reviewed health records of 256 children and teens diagnosed with migraines who were prescribed zonisamide as a preventive treatment. Among these participants, 28% had difficult-to-treat migraines, defined as migraines that had not responded to at least two other medications.

The researchers found that the median number of headache days per month dropped from 18 to six across all participants after starting zonisamide.

The greatest improvement was observed in the subgroup that followed up two to six months after beginning the medication, suggesting zonisamide is most effective after at least two months of use.

Zonisamide appeared to benefit both those with difficult-to-treat migraines and those without.

Zonisamide shares similarities with topiramate (Topamax), the only FDA-approved preventive migraine medication for children and teens. Both drugs are anticonvulsants that can help stabilize neuronal activity linked to migraines. However, zonisamide may have an advantage: it tends to cause fewer side effects compared to topiramate. The potential side effects include cognitive issues like memory and concentration difficulties, fatigue, weight loss, and others.

Dr. Kelley emphasized that while the findings are promising, the study has limitations. It did not include a control group of participants who were not taking zonisamide, and it relied on health record reviews rather than randomized clinical trials. Further research is needed to confirm these results and establish zonisamide’s effectiveness more conclusively.

I have been preferring zonisamide over topiramate in both children and adults. Both drugs have similar mechanisms of action and similar side effects, but topiramate causes more cognitive side effects, irritability, and depression. Topiramate is also more likely to cause kidney stones and severe metabolic acidosis. In older adults, both can cause osteoporosis.

My book, The End of Migraines: 150 Ways to Stop Your Pain, just became available as an audiobook on Amazon.

By: Dr. Mauskop

28-03-2025

Uncategorized

Check it out https://a.co/d/gwB2xEw

Medical Cannabis vs. Prescription Medications for Chronic Pain

By: Dr. Mauskop

23-03-2025

Alternative Therapies, Chronic migraine, Headache medications, Headaches, Migraine, New treatments, Pain, Pain Research

In a recent study published in Pain by the University of Pittsburg researchers, the effectiveness of medical cannabis was compared with traditional prescription medications for managing chronic pain.

The study involved 440 patients using medical marijuana and 8,114 patients treated with prescription medications (nonopioid or opioid) in the same healthcare system. Both groups received comprehensive pain assessments and treatment plans.

Key Findings

Response Rates: At three months, 38.6% of the medical marijuana group and 34.9% of the prescription medication group showed significant improvements in pain, function, or overall well-being. The response rate in the medical marijuana group remained stable at six months.

Opioid Reduction: Among the 157 patients in the medical marijuana group who were also prescribed opioids, there was a significant reduction in opioid use, with a mean decrease of 39.3% in morphine milligram equivalents over six months.

Comparative Effectiveness: The study found that medical marijuana was more effective than prescription medications for treating chronic pain, with patients being more likely to respond positively to medical marijuana.

This study suggests that medical marijuana may be at least as effective as, if not more effective than, conventional medications for chronic pain. It also highlights the potential of medical marijuana in reducing opioid use, which is a significant public health concern.

I prescribe medical marijuana to our migraine patients when prescription drugs and non-drug therapies are ineffective. For many, marijuana helps relieve nausea; for some, it helps with migraine-related anxiety and insomnia; and for a smaller proportion, it helps with pain. My observations are probably skewed by the fact that I prescribe medical cannabis only for people with more severe migraines. It may be more effective for people with mild migraines or migraines of average severity.

The Right Tempo in Music May Help Reduce Pain

By: Dr. Mauskop

17-03-2025

Alternative Therapies, Brain disorders, Headaches, Migraine, New treatments, Pain, Pain Research, Psychology of headaches

New research from McGill University published in the journal Pain suggests that the tempo—or speed—of music plays a crucial role in how well it helps reduce pain.

In this study, researchers explored whether music that matches a person’s natural rhythm—called their spontaneous production rate (SPR)—could provide better pain relief. SPR is the pace at which people naturally hum or tap out a tune, almost like a personal internal metronome.

Sixty participants first had their SPR measured by tapping out “Twinkle Twinkle Little Star” at a comfortable pace. Later, they were exposed to mild heat pain while listening to music specially adjusted to three tempos: their exact SPR, 15% faster, or 15% slower. A silent condition was also tested.

The results? Music alone reduced pain compared to silence, confirming what many of us know instinctively—music helps us cope. But the biggest surprise was that music adjusted exactly to each person’s SPR provided the most pain relief. Faster or slower versions just weren’t as effective.

Why does this happen? We think it may be because music at our natural tempo syncs better with our body’s internal rhythms, helping us relax and shift focus away from pain.

What does this mean for you? The next time you’re using music to manage discomfort—whether it’s during a workout, a medical procedure, or just a headache—try finding songs that feel “just right” in speed. It might be your body’s way of telling you it’s syncing up for maximum relief.

This research paves the way for more personalized music therapy—helping us move from simply picking our favorite songs to using science-backed soundtracks tuned just for us.

Here is a part of the chapter on music from my book, The End of Migraines, 150 Ways to Stop Your Pain, providing additional scientific evidence that music can relieve pain.

‘Music relieves experimental pain in healthy volunteers who are paid to endure pain and music. In one study, 18 volunteers were subjected to pleasant music, unpleasant music, and a silent period. Heat-induced pain was reduced only by pleasant music.

Children with migraines exposed to music improved as much as those given butterbur extract. Both groups improved more than a control group.

Music relieved the pain of osteoarthritis in the elderly. Those who listened to music for 20 minutes a day felt better than those who sat quietly for 20 minutes.

A study of 20 volunteers showed that both happy and sad melodies reduced heat pain. Listening to a lecture did not.

Another group of researchers examined the potential pain-relieving properties of three aspects of music: arousal, valence, and depth. Arousing music is characterized as “intense, forceful, abrasive, or thrilling”. Valence refers to “fun, happy, lively, enthusiastic, and joyful”. Depth means “intelligent, sophisticated, inspiring, complex, poetic, deep, emotional, and thoughtful.” The degree of arousal and the depth of music had a greater effect on pain than valence. The authors concluded, “With the advent of online music streaming services, this research opens new possibilities for music-based pain interventions.”

The new study suggests that tempo is another factor to consider when choosing soothing music.

Meeting of the Headache Cooperative of the Northeast

By: Dr. Mauskop

09-03-2025

Alternative Therapies, Chronic migraine, Cluster headaches, Headache medications, Migraine, neurostimulation

It was an honor to participate in the 35th Annual Winter Symposium of the Headache Cooperative of the Northeast, held on March 7 and 8. Leading headache experts from across the country covered many interesting topics. I had the privilege of discussing a presentation by Dr. Chiang Chia-Chun of the Mayo Clinic on artificial intelligence in Headache Medicine.

Here is my PowerPoint presentation: Artifical Intelligence discussion (1)

Vitamin B12: “Normal” blood Levels are often not normal

By: Dr. Mauskop

27-02-2025

Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine, post-traumatic headache, Science of Migraine

A new study published in the Annals of Neurology by researchers at UCSF challenges our current understanding of what constitutes “normal” vitamin B12 levels, particularly regarding brain health. The findings suggest that even B12 levels currently considered adequate may not be optimal for maintaining brain function, especially in older adults.

Key Findings

The study examined 231 healthy older adults with B12 levels that would typically be considered normal. Surprisingly, those with lower B12 levels – though still within the “normal” range – showed several concerning signs:

Slower nerve conduction in visual pathways

Reduced cognitive processing speed, particularly in older participants

More white matter damage visible on brain MRI scans1

Why This Matters

The current normal levels for vitamin B12 were determined decades ago, and it is not clear how reliable the research that led to these values was. Quest and Labcorp, two major chains of laboratories, define normal levels as 200 – 1,000 pg/ml and 232 -1,245 pg/ml, respectively. The WHO considers 480 pg/ml to be the bottom of the normal range, while it is 500 pg/ml in Japan. Some experts suggest these higher standards may contribute to lower rates of Alzheimer’s and dementia in Japan.

What This Means for You

Your B12 levels might be worth checking if you are experiencing neurological symptoms like:

Mental fogginess

Memory issues

Balance problems

Numbness or tingling

Migraine headaches, especially with visual auras

Dizziness

If you have this blood test done, don’t accept “it’s normal” from your doctor, but ask about your actual level.

Why are so many people deficient

Ironically, a healthy diet is low in vitamin B12. Vegetarians are at a greater risk of becoming deficient. Another common factor is antacid medications such as omeprazole (Prilosec), pantoprazole (Protonix), esomeprazole (Nexium), and others. Genetic factors also play a role.

Special Considerations for Older Adults

The study found that older adults may be particularly vulnerable to the effects of lower B12 levels. This is especially important because:

B12 absorption tends to decrease with age

The impact of lower B12 on cognitive processing speed was more pronounced in older participants.

A Breakthrough in Migraine Diagnosis

By: Dr. Mauskop

10-02-2025

Chronic migraine, Headaches, Migraine, Science of Migraine

Recent advances in neuroimaging are bringing us closer to an objective diagnosis of migraines. Korean researchers have published groundbreaking findings showing that migraine sufferers exhibit distinctive structural and functional brain characteristics visible on MRI scans. Their report, A robust multimodal brain MRI-based diagnostic model for migraine: validation across different migraine phases and longitudinal follow-up data, was published last month in the Journal of Headache and Pain.

Currently, migraine diagnosis relies on patients reporting specific symptoms. These include one-sided head pain, moderate to severe intensity, throbbing sensation, nausea, sensitivity to light and noise, and worsening pain with physical activity. A diagnosis typically requires the presence of at least three of these symptoms.

This new research confirms that migraines affect multiple brain networks rather than one area. The study identified three key markers: reduced thickness of certain parts of the brain’s cortex, changes in cortical folding patterns, and abnormalities in the brain’s visual, sensory-motor, and emotional processing networks. These findings represent a significant step toward more precise diagnostic tools for migraines. In the future, we may see a comprehensive diagnostic approach combining clinical symptoms, neuroimaging, and potentially other objective measures to provide more accurate diagnoses and targeted treatments.