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Tag "migraine"

Tension headaches can be prevented, or at least made milder by strength training, according to a new Danish study just published in the journal of the International Headache Society, Cephalalgia.

Tension-type headache is the most common type of headaches and it is usually accompanied by increased muscle tenderness.

The researchers compared muscle strength in neck and shoulder muscles in 60 patients with tension-type headaches and 30 healthy controls, using rigorous strength measurement techniques. Patients were included if they had tension-type headaches on more than 8 days per month and had no more than 3 migraines a month. Compared to controls headache patients had significantly weaker muscle strength in neck extension, which helps keep the head straight. Headache patients also showed a tendency toward significantly lower muscle strength in shoulder muscles. Among the 60 headache patients, 25 had frequent headaches and 35 had chronic tension-type headaches (defined as occurring on 15 or more days each month).

The use of computers, laptops, tablets, and smart phones has increased in recent years and this may increase the time people are sitting with a forward leaning head posture, which contributes to neck muscle weakness.

Neck pain and tenderness is a common symptom in both tension-type and migraine headache sufferers.

This is not the first study to show that muscle strength and weakness were associated with tension-type headaches, but it is still not clear whether the muscle weakness is the cause or the effect of headaches. Neck and shoulder strengthening exercises have been shown to reduce neck pain in previous studies and in my experience strengthening neck muscles will often relieve not only tension-type headaches, but also migraines. So it is most likely that there is not a clear cause-and-effect relationship, but a vicious cycle of neck pain causing headaches and headaches causing worsening of neck pain and neck muscle weakness.

Physical therapy can help, but the mainstay of treatment is strengthening neck exercises. Here is a YouTube video showing how to do them. The exercise takes less than a minute, but needs to be repeated many times throughout the day (10 or more). Many people have difficulty remembering to do them, so using your cell phone alarm can help. Other treatment measures include being aware of your posture when sitting in front of a computer or when using your smart phone, wearing a head set if you spend long periods of time on the phone, doing yoga or other upper body exercises, in addition to the isometrics.

Sometimes pain medications or muscle relaxants are necessary, while for very severe pain, nerve blocks and trigger point injections can help. Persistent neck pain can respond to Botox injections. When treating chronic migraines with Botox, the standard protocol includes injections of neck and shoulder/upper back muscles. Here is a video of a typical Botox treatment procedure for chronic migraines.

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

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

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

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

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

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

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

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

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

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

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

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Children with migraine headaches are usually given acetaminophen (Tylenol) or ibuprofen (Advil). A group of Italian doctors compared responses to these two drugs in kids with migraines who took a daily magnesium supplement to those who did not. Results of their study were published in the latest issue of the journal Headache. One hundred sixty children (80 boys and 80 girls) aged 5-16 years were enrolled and assigned to four groups to receive a treatment with acetaminophen or ibuprofen without or with magnesium. The dose of each drug was adjusted according to the child’s weight. Those children who were in the magnesium arm were given 400 mg of magnesium (the article does not mention which salt of magnesium was given – oxide, glycinate, citrate, or another). Migraine pain severity and monthly frequency were similar in the four groups before the start of the study. Both acetaminophen and ibuprofen produced a significant decrease in pain intensity, but not surprisingly, did not change the frequency of attacks. Magnesium intake induced a significant decrease in pain intensity in both acetaminophen- and ibuprofen-treated children and also significantly reduced the time to pain relief with acetaminophen but not ibuprofen. In both acetaminophen and ibuprofen groups, magnesium supplementation significantly reduced the attack frequency after 3 and 18 months of supplementation.

This study was not the most rigorous because it did not include a placebo group as the authors felt that placing children on a placebo would be unethical. However, it was rigorous in other respects and still provides useful information. The first conclusion is that taking magnesium reduces the frequency of migraines in children. The second is that taking magnesium significantly improves the efficacy of acetaminophen and ibuprofen.

The bottom line is that every child (and adult for that matter) should be taking a magnesium supplement. I have written extensively on the importance of magnesium because our research and that of others, including the above study, has consistently shown the benefits of magnesium. Unfortunately, after dozens of publications, hundreds of lectures, and recommendations from medical societies, many doctors still do not recommend magnesium to their migraine patients. Some are not familiar with the research, others dismiss any supplements out of hand, and yet others do not believe the studies because they think that magnesium is too simple and too cheap to be effective. Most doctors are trained to prescribe drugs and they feel that patients expect prescription drugs, so giving them a supplement will disappoint the patient and will reduce doctor’s standing in patients’ eyes. This is clearly not the case since many people prefer more natural approaches and because recommending a supplement does not mean that a prescription drug cannot be also given. In fact, magnesium improves not only the efficacy of acetaminophen and ibuprofen, but also prescription drugs such as sumatriptan (Imitrex).

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White matter lesions that often seen on MRI scans of adult migraine sufferers were also found in children. A study by Washington University researchers inn St. Louis examined MRI scans of 926 children 2 to 17 years of age (mean age was 12.4 and 60% were girls) who were diagnosed with migraine headaches. They found white matter lesions (WMLs) in about 4% or 39 of these children, which is not much higher than in kids without migraines. Just like in the adults, these WMLs were slightly more common in kids with migraine with aura. None of these lesions were big enough to be called a mini-stroke or an infarct. There was no correlation between the number of lesions and the frequency or the duration of migraines. In conclusion, WMLs in children with migraines do not appear to be caused by migraines and are most likely benign in origin. The origin, however remains unknown, which often causes anxiety in parents of these children.

Unlike in children, adults with migraines and especially those with migraines with aura, are much more likely to have WMLs than adults without migraines. But even in adults, these appear to be benign as I mentioned in my previous post.

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Transcranial magnetic stimulation (TMS) seems to be effective for the treatment of migraines with aura. “Spring TMS” device which delivers a jolt of such stimulation has been on the market in Europe since 2011. The American company that manufactures this device, eNeura Therapeutics hopes to obtain approval to sell it in the US in the near future. The approval of this device in Europe was based on a multi-center study results of which were published in Lancet Neurology. Unfortunately, the device is fairly bulky and needs to be carried around constantly because it seems to work only if used during the aura phase of the migraine. Auras usually begin unpredictably and last 20-60 minutes. Migraine with aura affects only 15-20% of all migraine sufferers, further limiting the potential market for this device.

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

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

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

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Migraine and epilepsy drug Topamax is being recalled by its manufacturer, Ortho-McNeil Neurologics, a division of Johnson and Johnson. This recall affects only two lots of 100 mg tablets. This recall does not affect topiramate, generic copies of this brand. Since the generic form is much cheaper, most patients have switched to it from branded Topamax. This adds another problem to this beleaguered drug. It was recently reclassified by the FDA from pregnancy category C to category D, which means that it is much more dangerous for the fetus than originally thought. Topiramate is also associated with a high incidence of kidney stones (20%) and can cause other serious problems. This is why we always emphasize non-drug approaches (exercise, acupuncture, biofeedback magnesium, Botox, etc), which can be more effective and are much safer than drugs.

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Obese people are more likely to suffer from more frequent and severe migraine headaches. The question that remained unanswered was whether losing weight helps relieve headaches. A new study just published in the leading neurology journal, Neurology suggests that this may be the case. Researchers from Brown University in Providence, RI examined 24 severely obese patients before and after bariatric (weight reduction) surgery. Their mean body mass index (BMI) was 46 and their mean age was 39. A direct correlation between the amount of weight loss and the reduction in the number of headache days was observed. Weight loss was also associate with reduced disability. This study gives scientific support to the idea that weight loss may improve migraine headaches.

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Melatonin does not seem to be effective for the prevention of migraine headaches, according to a study published in Neurology. The researchers from Norway gave 2 mg of extended release melatonin every night for 8 weeks to 46 migraine sufferers. All 46 received also received 8 weeks of placebo and neither the doctors nor the patients knew whether the first treatment was with melatonin or placebo (so called double-blind crossover trial). Migraine frequency did improve from an average of 4.2 a month to 2.8, but the same results were observed while on melatonin as on placebo. This study confirms a well established observation that taking a placebo helps, or perhaps that what helps is just keeping track of your headaches and seeing a medical provider on a regular basis.
One argument against the validity of the study is that the dose of melatonin might have been too low because one small trial of 10 mg of melatonin in cluster headache sufferers did show benefit. Another possibility is that the dose was too high. There is a study that suggests that taking 0.3 mg (or 300 mcg) helps insomnia, while 3 mg does not. Anecdotally, I find that for me and many of my patients 0.3 mg works better for insomnia and jet lag than 3 mg.

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Botox, which was recently approved for the treatment of chronic migraine headaches, was originally thought to relieve migraine headaches by relaxing tight muscles around the scalp.  However, several recent studies determined that besides relaxing muscles, Botox also stops the release of several neurotransmitters from the nerve endings.  These neurotransmitters are released by messages sent from the brain centers that trigger a migraine attack.  In turn the released neurotransmitters send pain messages back to the brain completing a vicious self-sustaining cycle.  A meticulous study just published in the journal Pain by Danish researcher confirmed that injections of Botox stop the release of neurotransmitters and reduce sensitivity of rat’s chewing muscles.  Not knowing the exact way how Botox works makes many doctors skeptical about its efficacy.  However, we have no idea how preventive medications, such as beta blockers, antidepressants and epilepsy drugs prevent headaches either.  These drugs, like Botox, were also discovered to help headaches by accident.  This does not and should not stop us from using them.  Botox is more effective and safer than medications taken by mouth and is an excellent option for over 3 million Americans who suffer from chronic migraines.

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Botox was just approved by the FDA for the treatment of chronic migraine headaches.  This is great news to the more than 3 million chronic headache sufferers in the US (people who have more than 15 days with headaches each month).  In Dr. Mauskop’s opinion Botox is one of the most effective treatments for frequent and severe headaches and it is the first treatment approved FDA for chronic migraines. Dr. Mauskop was one of the first headache specialists to begin using this treatment more than 15 years ago. He has published several scientific articles and book chapters on the use of Botox for headaches. His most recent chapter on Botox for headaches was just published a month ago in the 97th volume of the Handbook of Neurology (Elsevier).  Dr. Mauskop has trained over 200 doctors from all across the US, Canada and Europe who traveled to the New York Headache Center to learn this technique.  Initial reports of the use of Botox for headaches were met with disbelief, while strong skepticism about the efficacy of this treatment persisted for many years. The main reason for this skepticism was the fact that migraine headaches are known to originate in the brain, while Botox affects only muscles and nerves on the outside of the skull. A large amount of research led to our current understanding of how Botox works: while the brain begins the headache process, it requires feedback from nerves and muscles on the surface of the head. By blocking activation of the nerves and muscles the feedback loop remains open and the headache does not occur. After the first few treatments some patients still develop a migraine aura or just a sensation that the headache is about to start, but it does not. After repeated treatments even the auras and this sensation stops occurring. Botox seems to be effective in 70% of patients, which is a rate significantly higher than with any preventive migraine medications, such as Topamax (topiramate), Depakote (divalproex sodium), Inderal (propranolol), or Neurontin (gabapentin). These drugs are effective in less than 50% of patients who try them. The other 50% do not respond or develop unacceptable side effects. Lack of serious side effects is another big advantage of Botox over medications. Botox can cause cosmetic side effects, such as a surprised look, droopy eyelids, or one eyebrow being higher than the other. These and other side effects become less common as the doctor who performs them becomes more experienced. Occasionally, patients develop a headache from being stuck with a needle. This is also uncommon because the needle is very thin and if done correctly, the procedure usually causes very little pain. The effect of Botox begins about 5-6 days after the injections, but the improvement continues to occur for 3 months, at which point the second treatment is given. Some patient require Botox injections at 2 month intervals. Published studies have shown that the second treatment is usually more effective than the first and the third one is better than the second. After several treatments some people improve completely (a small percentage of patients stop having all of their headaches after the first treatment). Dr. Mauskop’s experience suggests that children as young as 10 who suffer from daily headaches also respond well to Botox injections. The major drawback of Botox is its cost. However, several insurance companies have been paying for this treatment and with the FDA approval most of them will have to cover this treatment for patients with chronic (more than 15 days a month) headaches.

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A new treatment for motion sickness in patients with migraines was reported by a group of doctors from Pittsburgh.  Giving migraine sufferers who are prone to motion sickness a migraine drug, rizatriptan (Maxalt) prevented motion sickness . There were 25 subjects in the study and 15 of them developed motion sickness after being rotated in the darkness. Of these 15 patients, 13 showed decreased motion sickness after being pretreated with rizatriptan. This was a small study and not all patients benefited, but this is an option that should be considered in patients who suffer from severe motion sickness.  It is likely that the effect is not specific to rizatriptan, but that sumatriptan (Imitrex), eletriptan (Relpax) and other triptans are also effective.  However, just like when treating migraine attacks, it is possible that some patients will respond better to one triptan and others to another.

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

 

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

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Aspirin and similar anti-inflammatory drugs have been proven to be effective for many migraine sufferers.  In a recent report 1,000 mg of aspirin was found to be as effective as 100 mg of sumatriptan (Imitrex) with fewer side effects.  Cambia is a new prescription drug, which was recently approved by the FDA specifically for the treatment of migraine headaches.  The active ingredient in this drug is diclofenac, which is also sold under Voltaren and Cataflam names.  But unlike other forms of diclofenac, Cambia is a powder which patients are supposed to dissolve in a glass of water and drink it.  Drinking a solution rather than swallowing a pill speeds absorption of the drug, which can make a difference for those migraine sufferers who need to catch their attacks early, or drugs don’t help.  The drug has a “black box” warning, which cautions about possible cardiovascular side effects, as well as gastro-intestinal side effects, including bleeding and ulcers.  The cardiovascular side effects of diclofenac are similar to those of Vioxx which was taken off the market.  Other NSAIDs also carry risk of cardiovascular (and GI) side effects, but their risk is lower.  The only NSAID without cardiovascular risks is aspirin.  In fact it is used to prevent strokes and heart attacks.  Aspirin is also the only drug which prevents the development of rebound headaches – worsening of headaches from frequent intake of a headache medicines or caffeine.

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Severe migraines are often accompanied by nausea and vomiting, making oral medications ineffective.  Sumatriptan (Imitrex) and Zomig (zolmitriptan) are available in a nasal spray and Imitrex also as an injection (a needleless injection, Sumavel was launched recently).  Nasal spray is not well absorbed and does not work well for many (in my experience, Zomig spray is somewhat better than Imitrex).  Injections work fast, but are painful (even the needleless injection hurts) and expensive.  Another way to get medicine into the body is rectally.  Rectal suppositories are absorbed very quickly and more consistently than nasal sprays.  Europeans are much more receptive to this route of administration than the Americans.  A group of Italian researchers compared  the effect of a suppository containing 25 mg of sumatriptan with a 50 mg tablet.  The suppository was slightly more effective than the tablet.  Imitrex suppositories are not available, but so called compounding pharmacies can prepare a suppository of any medication, if doctor writes an order.  With Imitrex going generic, the price should be more affordable.

There are two other products in development (not yet available), which will bypass oral route – a sumatriptan skin patch and an inhaler of dihydroergotamine (Levadex).  The patch is somewhat large and may be awkward to use, while the inhaler is much more promising.  Inhaling a drug into the lungs provides very fast onset of action, faster than subcutaneous injection of Imitrex.  According to the published data the efficacy of Levadex is very good with few side effects.

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

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It is very exciting to finally have two published studies (PREEMPT 1 and PREEMPT 2) which provide definitive proof that Botox is effective for chronic migraine headaches.  More than 15 years ago a plastic surgeon in California, Bill Binder reported that many of his patients treated with Botox for wrinkles found relief from headaches.  Everyone was very skeptical, but having many patients who failed every other treatment and having learned that Botox is very safe if used properly, I decided to try it.  To my great surprise Botox worked exceptionally well.  My most dramatic experience was in a 76-year-old woman who suffered from daily headaches for 60 years.  She had failed a long list of medications, nerve blocks, acupuncture and other treatments.  After the first Botox treatment, for the first time in 60 years she went for three months without a single headache.  Her neurologist came to my office to learn the technique I developed and has been using Botox in his practice ever since.  More than 200 doctors from around the world came to our Center to learn how to use Botox for headaches.  They were all searching for new treatments for their desperate patients.  At the same time most of the medical community had remained very skeptical and dismissive of this approach.  They could not believe that Botox could help headaches and wanted to see double-blind, placebo-controlled trials before using it in their patients.  Well, now they have it, but over the past 15 years many of their patients could have benefited from this safe and effective treatment.  Yes, we do need proof that any new treatment works, but when this treatment is safe and there are no better alternative, it is appropriate to try it before definitive proof is available.  We hope that these two studies will lead to the FDA approval of Botox for the treatment of chronic migraines before the end of 2010, which will make it easier for patients to obtain insurance reimbursement.

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

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Some headaches, usually migraines, do not respond to the usual over-the-counter and even prescription headache medications.  Once it is clear that there is no serious underlying cause, such as an aneurysm, several injectable medications can be given in an emergency room (during office hours at the New York Headache Center we also give injections in the office). These medicines may include intravenous injections of: magnesium sulfate (which is not a medication, but a mineral), sumatriptan (Imitrex, which can be self-injected by patients at home), ketorolac (or it is also called Toradol, which is a drug in the aspirin family), dexamethasone (Decadron, a steroid drug, which can help pain of almost any type, but cannot be given for long periods of time), prochlorperazine (or Compazine, which is a nausea medication but can help pain as well), valproate sodium (Depacon), and several other drugs.

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

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There are several effective preventive medications for migraine headaches, however they are prescribed to only a small number of people who could benefit from them.  A study by Dr. Richard Lipton in the journal Cephalagia and his colleagues discovered that only 13% of migraine sufferers are taking preventive medications, but those who do have significantly less disability than those who don’t. Among possible reasons, doctors who don’t realize how disabling migraines are, patients how think that medications are dangerous or will cause side effects. Cost does not seem to be a factor because all patients in this study had insurance and most of these medications are inexpensive. Patients are often reluctant to take medications, but would rather find and remove the cause. Unfortunately, in most cases migraine is a genetic disorder and true cure is not possible. However, for most migraine sufferers it is possible to find and remove triggers which make headaches worse. If this is not sufficient, magnesium, CoQ10, other supplements, biofeedback, Botox injections, and regular exercise can provide relief without drugs. If all this still does not provide relief, medications, such as anti-depressants, epilepsy drugs, and high blood pressure drugs can be very effective and improve the quality of life.

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

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One of the oldest preventive headache medications for migraines is propranolol (Inderal), which belongs to the family of blood pressure medications called beta-blockers.  There are newer and better beta-blockers, such as nebivolol (Bystolic), which have fewer side effects than propranolol.  We also use other types of blood pressure medications, such as calcium channel blockers (verapamil or Calan, and other) and ACE inhibitors (lisinopril, or Zestril/Prinivil is one example).  The newest category of blood pressure medications is ACE receptor blockers (ARBs) which are at least as effective and have fewer side effects than ACE inhibitors.  The best scientific evidence (from a single double-blind study) for the efficacy of ARBs in migraines is for candesartan (Atacand).

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74% of girls and 52% of boys have headaches at age 17, according to a Finnish study of 6,262 twins.  At age 11, 60% of girls and 59% of boys had headaches at least once a month.   The prevalence of weekly headaches increase d in girls from 16% to 25% between ages 11 and 14.  Headaches in kids is a major problem, but unfortunately it does not receive proper attention.  Sometimes parents do not believe that their child has a headache or if they do, they are reluctant to take the child to a doctor because they don’t want to resort to prescription medications.  Fortunately, many non-drug approaches are very effective in kids.  Regular sleep schedule (very hard to enforce in teenagers), regular meals, frequent aerobic exercise, biofeedback or meditation, and supplements can be very effective.  Several studies have shown that kids with headaches are often deficient in magnesium, riboflavin (vitamin B2), and Co-enzyme Q10 (CoQ10).  If a child still has headaches, a medications may also be appropriate.

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

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

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A blinded study comparing Botox with Topamax for the prevention of migraine headaches was conducted by Drs. Jaffri and Mathew and published in the current issue of Headache.  They enrolled 60 patients and divided them into two groups – one group received real Botox and placebo tablets, while the second group received saline water injections instead of Botox, but were given tablets of Topamax.  At the end of 9 months and after 2 Botox treatments the efficacy of these two treatments was the same, but many more patients in the Topamax group developed side effects and dropped out of the study.

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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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Some migraine patients are more disturbed and disabled by migraine aura symptoms than by the headache itself.  Some people do not even have pain but only auras.  In the majority the aura is visual and consists of squiggly lines, flashing lights, distorted vision, or partial loss of vision on one side of each eye.  Less often people experience numbness of one side of the body, dizziness, or vertigo.  These symptoms are sometimes more difficult to treat than the pain.  Anecdotal reports suggest that a blood pressure drug belonging to the family of calcium channel blockers can help.  Another medication that has been reported to be effective (also only in case series and not double-blind trials) is an epilepsy drug, lamotrigine (Lamictal).  The effective dose of lamotrigine varies from 100 to 500 mg day, while verapamil is usually effective at 12-240 mg, although in some patients only much higher doses are effective.

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Two large trials of Botox provide unequivocal proof of its efficacy in the treatment of chronic migraine headaches.  The results of these two double-blind, placebo-controlled studies (I participated in one of the two trials) of onabotulinumtoxinA (Botox) in chronic migraines were presented at the International Headache Congress in Philadelphia last week.  Botox was proven to reduce the number of days with headaches, improve multiple headache symptoms, and improve the quality of life.  The treatment was extremely well tolerated with very few side effects overall and no serious side effects.   Having used Botox for the treatment of various headache types for over 15 years in several thousand patients it is very gratifying to finally have well-designed trials which confirm my and my colleagues’ experience.   The manufacturer is submitting the results of these trials to the FDA and we expect to have approval of Botox for the treatment of chronic migraines by the end of 2010.  FDA approval will force insurance companies to pay for this highly effective treatment and will make it affordable for people who desperately need it.

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

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

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Migrainous vertigo seems to respond to intravenous infusion of a high dose of corticosteroids, according to a report in the latest issue of Headache by a group of Indian doctors.  Two of their patients had intermittent episodes of severe vertigo and two had chronic vertigo.  All four respond to infusions of 1 gram of methylprednisolone.  One require 3 infusions, one needed 2 and in another 2 vertigo stopped after a single infusion.  We routinely use corticosteroids for severe migraine attacks when other medications fail.  While occasional (once or twice a month) use of corticosteroids is relatively safe, frequent or daily intake of corticosteroids (besides methylprednisolone, these drugs include prednisone, prednisolone, and dexamethasone) can lead to dangerous side effects.  It is possible that oral corticosteroids will produce a similar effect as an infusion and may be worth trying when nothing else helps relieve the vertigo.

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A blood pressure medication telmisartan (Micardis) was shown to be effective in the prevention of migraine headaches by a group of German researchers led by H-C Diener.  Several blood pressure medications have been proven to prevent migraine headaches.  The oldest category of blood pressure drugs, beta-blockers have the most evidence to support their use and two of them (propranolol and timolol) are approved by the FDA for the preventive treatment of migraines.  However, beta-blockers are not high on my list because they tend to cause more side effects than other blood pressure medications.  The most common side effects are due to excessive lowering of blood pressure – lightheadedness, fatigue, and fainting.  They also slow down the heart rate, which can make it difficult to exercise, while regular aerobic exercise is the first treatment I recommend to my headache patients.  Calcium channel blockers, such as verapamil, are not as effective for migraine prevention as they are for the prevention of cluster headaches and can cause constipation, swelling and irregular heart beats.  Another blood pressure medication, lisinopril which belong to the family of ACE inhibitors has also been shown to prevent migraine headaches.  The most common limiting side effect of ACE inhibitors is coughing.  A newer group of medications, which are similar in action to ACE inhibitors is ACE receptor blockers, or ARBs.  ARBs do not cause coughing and telmisartan which is one of the ARBs caused as few side effects as the placebo.

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

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

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

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In my post 2 years ago I wrote about surgery for migraines and the many reasons why Botox injections is a better option than surgery to permanently cut nerves and muscles.  I also wrote that there were no controlled studies to show that surgery actually works.  Now we do have one study.  The study was blinded, which means that some patients had nerves and muscles cut, while others had only a skin incision.  The results were much better in patients who had real surgery.  The plastic surgeons who performed the study tried their best to produce a blinded study, but they admit that blinding is far from perfect since patients who had real surgery can see their muscles shrink or not move.  But even if we accept that blinding was achieved and surgery indeed provides relief of headaches, all of my other arguments stand.  These include surgical risks (bleeding, infection, scarring, and persistent nerve pain) and high cost.  Yes, Botox is expensive too, but migraine usually is not a life-long illness and migraine attacks often stop for long periods of time or permanently with or even without treatment.  I have seen many patients whom I treated with Botox every 3 months and whose headaches stop after a year or two.  Two years of Botox treatments is significantly cheaper than surgery and it does not carry all of the surgical risks.

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

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Medications used for the preventive treatment of migraine headaches can cause weight loss, but more often cause weight gain.  An interesting study by Dr. Bigal and his colleagues, just published in Cephalalgia looked at this effect of drugs in 331 patients.  They found that 16% of them gained weight (5% or more of their baseline weight) and 17% lost weight.  The various treatments given to these patients were equally effective in both groups.  However, not surprisingly, those who gained weight had elevation of their cholesterol, blood glucose, blood pressure and pulse.  Patients who have migraine headaches with aura (about 15-20% of migraine sufferers) already have an increased risk of strokes, so adding additional risk factors for both strokes and heart attacks should be especially avoided in this group.  The only preventive migraine drug which consistently lowers weight in many patients is topiramate (Topamax).  This drug is now available in a generic form, making it much less expensive.  While topiramate does lower weight and helps prevent migraine headaches only half of the patients stay on it.  For the other half it causes unpleasant side effects (memory impairment and other) or it does not work.

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In addition to an injection, tablet and a nasal spray, sumatriptan is being tested in two other formulations.  No, it is not an inhaled form, which I just posted in my previous blog (dihydroergotamine inhaler), but through a skin patch and by a “lingual spray”, that is a spray into the mouth.  The skin patch may work fast and will deliver medicine through the skin, bypassing the stomach, which would be very useful for people who get very nauseous and have difficulty swallowing medications.   However, it is quite a large patch and will probably cost significantly more than a tablet, particularly in the generic form.  The second new formulation, a spray into the mouth, appears to partially absorb in the mouth and partially in the stomach, making it also work faster, although so far it looks to be only as effective as a 50 mg tablet.  The usual dose is 100 mg.  Also, hopefully the company that is developing this product has been able to mask the taste of sumatriptan.  Patients who have tried the nasal spray often complain of a very unpleasant taste, which can make nausea worse.

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Trials of an inhaled version of an old migraine drug show surprisingly good results.  The drug is dihydroergotamine and in injectable from is considered to be one of the strongest migraine medications.  It is often used intravenously to treat severe migraines that do not respond to other therapies and for medication overuse headaches.  It can be also injected into the muscle, under the skin or sprayed into the nose.  The main problem with this drug is that it often makes nausea worse or even causes severe nausea in patient who do not have it.  What is surprising about the new product being developed by MAP Pharmaceuticals (to be called Levadex if and when FDA approves it) is not that is is very effective, but that it causes significantly less nausea than the same drug in an injectable form.  Another advantage is that inhaling the medicine into the lungs results in a very quick delivery of the drug into the circulation – as quick as an injection but without a needle.  A similar product, Ergotamine Medihaler was available until about 15 years ago, but was withdrawn because of manufacturing difficulties and limited demand.  The demand for this new product will also be limited because it will be more expensive than a tablet of any migriane drug, it will be more bulky to carry around, and will be mostly utilized by patients who cannot take oral medications due to nausea or by those who need very quick onset of action to abort an attack.

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

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Imitrex and Topamax are two migraine medications that recently lost their patent protection and became available in a generic form, under the names of sumatriptan and topiramate.  Many patients are concerned about the quality of generic products.  A recent study published in Neurology looked at 948 patients with epilepsy who were treated with generic Topamax (it is approved for the treatment of both migraines and epilepsy).  Compared to patients who used the branded Topamax, those on generic substitutions needed to have more of other medications, were admitted to the hospital more frequently and stayed in the hospital longer.  The risk of head injury or fracture (presumably due to seizures) was almost three times higher after the switch to a generic drug.

Clearly, migraine patients do not run the same risk as epilepsy patients of having a seizure or being admitted to the hospital, however a small number of patients can have worsening of their migraines.  The main reason is the legally permitted variation in the amount of medicine in each tablet.  Taking a higher dose of the generic drug can help.

The same applies to Imitrex – a small number of patients will find that the generic sumatriptan is slightly less effective.  The only, albeit significant, advantage of the generic drugs is cost savings.  At this point we have only one generic substitution for Imitrex and the price difference is only 20%, but in a few months more generics will appear and the price should drop significantly, which is a very welcome development for patients with frequent migraines.

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Occipital nerve stimulation appears to be a promising new treatment for migraine and cluster headaches.  Phase II trials performed by Medtronics, the manufacturer of one type of  stimulator, have been positive.  This stimulator requires implantation of a stimulator wire next to the occipital nerves and a separate incision to implant a stimulator device with a battery in the upper chest.  A recent report suggests that the same effect can be achieved by implanting a small self-contained device without the need for wires, large battery, or a separate incision.  This “Bion Microstimulator” has not been subjected to any extensive studies similar to ones  performed by Medtronics, but the preliminary data looks promising.

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

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

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

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

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

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Physical inactivity was strongly associated with headache disorders, according to a large study by Swedish researchers published in Headache.  They looked at 43,770 people with recurrent headaches and migraines and found that economic hardship and psychosocial factors (poor social support and experience of being belittled) seem to play a role in headache disorders.   Of lifestyle factors, physical inactivity was strongly associated with headache disorders, while smoking to a lesser extent.  Skipping breakfast, being overweight and underweight seemed to be connected to headaches.

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Red wine to relieve migraine?  Red wine is a well-known trigger of migraine headaches (although French tend to disagree).  A recent study published in journal Pain found that resveratrol, the active ingredient in red wine which is responsible for its health benefits, has pain relieving properties when given to rats.  There have been no reports in the literature or from my own patients that resveratrol causes headaches and judging from this study, it may in fact help.

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Treatment of menstrual migraines often is more difficult than of non-menstrual attacks.  A double-blind study by Marcelo Bigal and his collaborators just published in Headache shows that a combination of 10 mg of rizatriptan (Maxalt) and 4 mg of a steroid medication, dexamethasone (Decadron) is more effective than either drug alone.  Both drugs are effective in treating many refractory migraine attacks (although I usually use 8 mg of dexamethasone), this is the first trial of two drugs together.  While the results are not very surprising, the study may lead to wider acceptance of combination therapy and better relief for many women.  While in the past the emphasis was placed on finding a single drug to treat a disease, in recent years combination therapy has become a standard approach in many conditions.  Treximet, a combination of sumatriptan (Imitrex) and naproxen (Aleve) was also shown to be better than either of the two ingredients alone.

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Migraines may be helped by omega-3 fatty acids, a supplement that has gained well deserved popularity.  Several recent studies suggesting benefits for the cardiovascular system prompted me to look at the headache literature.  An article in Cephalalgia in 2001 by Pradalier and his colleagues concluded that this supplement is ineffective, at least when they looked at the number of headaches in the last 4 weeks of treatment.   However, the active treatment with 6 grams of omega-3 fatty acids was significantly better than placebo when they looked at the total number of attacks during the entire 4 months of treatment.  Taking into account this finding and considering that omega-3 fatty acids have other benefits while being very safe, it is worth trying to take daily 6 grams of omega-3 fatty acids if you suffer from migraine headaches.

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Refractory migraines may respond to occipital nerve stimulation, according to Dr. Joel Saper who led a multicenter trial of this treatment.  An electrode was surgically implanted in the back of the head, where the occipital nerve is located, and a pacemaker-size device was implanted under the skin.  The trial looked at 110 patients who had more than 15 days with migraines each month and who did not respond to a variety of medications.  66 patients completed the diary information for three months following the start of treatment.  The results were encouraging – 39% of patients improved, compared with 6% in the control group.  None of the patients had any adverse events.

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

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

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Magnesium is effective in preventing migraine headaches according to a new study published in the last issue of journal Magnesium Research.  The researchers found that patients treated with magnesium, compared to those treated with placebo, had fewer migraine attacks and the attacks were milder.  In addition, magnesium treated patients had improved blood flow in their brains, while those on placebo did not.  This is just another confirmation of previous findings of the efficacy of magnesium in the treatment of migraine headaches.  Since magnesium is very inexpensive and extremely safe, every patient with migraine headache should be given a trial of magnesium supplementation.

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15,056 patients with migraine and tension-type headaches were treated with acupuncture in a largest acupuncture study, which was financed by the German government.  Results published in the latest issue of journal Cephalalgia by S. Jena and colleagues indicate that “acupuncture plus routine care in patients with headache was associated with marked clinical improvements compared with routine care alone”.  This study should dispel any remaining doubt about the efficacy of acupuncture in the treatment of headaches.

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Vitamin D deficiency has become a very popular topic in lay and professional literature, and deservedly so.  Vitamin D is important not only for bone health, but for normal functioning of many organs.  Its deficiency appears to be much more common than it was previously suspected.  Dr. Steve Wheeler has found vitamin D deficiency in 42% of 55 patients with chronic migraine headaches.  He presented these findings at the recent meeting of the American Headache Society.  We do not have evidence that taking vitamin D will help relieve headaches, however if a deficiency is present correcting it can certainly improve overall health of the patient.  One possible cause of what appears to be increasing incidence of vitamin D deficiency is widespread use of prescription and over-the-counter antacids.  Reducing stomach acidity helps relieve heartburn and other symptoms of reflux, but it may also interfere with absorption of vitamins and minerals.

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

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Treating migraines in adolescents presents some unique challenges.  Besides difficulties, such as getting them to bed before midnight and getting them to improve their diets, we face the problem of not having any FDA-approved drugs to treat migraine attacks.  And it is not for lack of trying on the part of makers of triptans, which are drugs that work miracles for many adult headache sufferers.  The problem has been proving to the FDA that these drugs work in kids.  Because children tend to have shorter attacks, by the time we try to assess the efficacy of a particular drug two and four hours after the pill is taken, the headache is gone even if the pill was a placebo.  Many studies have shown that the triptans are safe and effective (as was observed in kids who have longer duration of attacks).   Many, but far from all headache specialists use triptans, such as Imitrex and Maxalt in adolescents.  A study just published in Headache proved that Axert, another drug in the triptan family and that was tested in 866 children, is effective in children 15 to 17 years of age.  The bottom line is that triptans can be safely used in kids who suffer from severe migraine headaches.  I am often asked by other physicians, what is the youngest age I would prescribe a triptan?  Because of a shortage of pediatric neurologists I feel compelled to see children as young as 10 and this is the youngest age at which I will prescribe triptans.

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

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Menstrual migraines are at times very difficult to treat.  Triptans, such as Maxalt, Imitrex and other are usually very effective, but in some patients do not provide sufficient relief.  Corticosteroid drugs, such as prednisone and dexamethasone can help some patients.  Marcelo Bigal and his colleagues compared treatment of menstrual migraines with Maxalt alone, dexamethasone alone, and combination of the two.  Maxalt was much better than dexamethasone, providing sustained 24-hour relief in 63% of patients vs 33%, but the combination was better than Maxalt alone, giving relief to 82% of women.  We would always try Maxalt or a similar drug alone, but if one drug is insufficient a combination with dexamethasone should be tried.  Corticosteroids should not be used for more than a few days a month because frequent and prolonged use can lead to serious side effects.

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

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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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Treximet, a new migraine treatment was approved today by the FDA.  Treximet is a combination of two old drugs – sumatriptan (Imitrex), 85 mg and naproxen (Aleve), 500 mg.  The combination is more effective than Imitrex alone because naproxen provides additional relief through its anti-inflammatory and pain relieving effects.  Imitrex is losing its patent protection and is going to be available as a generic drug in 2009.  The maker of Treximet, GlaxoSmithKline is hoping to switch most of the patients currently taking Imitrex to Treximet before patent expiration, in order to reduce its losses to generic competition.  However, it is likely that insurance companies will force physicians to prescribe generic Imitrex and generic naproxen rather than pay for Treximet.  GSK argues that the combination drug, just like Imitrex are fast-dissolving and therefore faster acting drugs than the generic naproxen is and the generic Imitrex is going to be.

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

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Migraine and cluster headaches that do not respond to the usual treatments, may improve with injections of histamine.  Dr. Seymour Diamond of the Diamond Headache Clinic in Chicago has pioneered the use of histamine in cluster headaches.  We have found that in cluster headache patients for whom nothing else works histamine often provides excellent relief.  A recent study published in the journal European Neurology suggests that histamine injections may also help migraine patients. 

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A new drug may be better for the prevention of migraines than the old ones in the same category.  A study just published in Headache suggests that nebivolol, a beta-blocker just approved in the US for the treatment of high blood pressure may be as effective as old beta-blockers, but with significantly fewer side effects.  Beta-blockers, such as propranolol (Inderal), timolol (Blocadren) metoprolol (Toprol), atenolol (Tenormin) and nadolol (Corgard) have been used for the prevention of migraines for many years.  However, many patients could not tolerate them because of side effects, mostly fatigue, slow heart beat and low blood pressure.  Nebivolol appears to cause these side effects 50% less often, while preventing migraine attacks with equal efficacy. 

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Anti-epilepsy drugs such as Neurontin (gabapentin), Topamax (topiramate) and Depakote (divalproex) have been proven to prevent migraine headaches.  Each drug works for about half of the patients who try it.  The other half either does not get any benefits or develops side effects.  This does not seem to be that effective, but these drugs do beat placebo in blinded trials.  We also know that not all anti-epilepsy drugs work for headaches.  Tegretol (carbamazepine) was never shown to help and a study just published in Neurology confirms our impression that its cousin, Trileptal (oxcarbazepine) does not work either.  We do occasionally see good results with two other epilepsy drugs, Keppra (levetiracetam) or Lamictal (lamotrigine), but large  clinical trials proving their efficacy are lacking.

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Memantine is an old medication which has been available in Europe for over 30 years, but was only recently introduced in this country for the treatment of Alzheimer’s disease.  Memantine blocks a specific receptor in the brain cells.  Activation of this so called NMDA receptor is responsible for many negative effects, including pain and nerve cell damage.  As soon as the drug was introduced in the US pain and headache specialists tried using it for pain, but probably because it is a weak blocker of the NMDA receptor our experience with this drug has not been very impressive.  However, in the recent issue of journal Headache Greek doctors report that one patient with chronic migraines obtained complete relief due to memantine.  One case report clearly does not prove that memantine is going to work for any significant percentage of patients.  However, this drug has relatively few side effects and if the usual treatments fail it may be worth trying.

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Topamax is a popular drug for the prevention of migraine headaches.  IT works for about half of the patients who try it.  The main problem that makes people stop taking the drug is cognitive side effects.  Patients tell us that they feel “stupid” on this drug.  An article just published in the European Journal of Neurology pinpoints the main cognitive problem, which turns out to be word fluency.  This means having trouble coming up with the right word. 

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Bright light can trigger migraine headaches and many migraine sufferers have increased sensitivity to light during an attack.  A recent report has suggested that wearing amber colored lenses (Nike Maxsight) can relieve the light sensitivity.  For some of our patients wearing these lenses has allowed them to go outdoors on a sunny day without getting a migraine.  A new report in the journal Drug Development Research proposed a theory that each patient might best benefit from an individually selected tint (PSF, or precision spectral filters).  The article, Prevention of visual stress and migraine with precision spectral filters presents a convincing argument which should be relatively easy to test.  PSF appears to be more easily available in the UK where most of the research has been conducted.  

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Clopidogrel, which is also known as Plavix, is a drug used to prevent strokes and heart attacks.  It works by preventing platelets from sticking together and causing a blood clot which can block a vessel in the heart or brain.  Platelets also tend to become sticky in patients during a migraine attack, which is how this drug might help migraine sufferers.  A British physician reported that a small number of patients given this drug stopped having migraine headaches after many years of unsuccessful treatments.  A large study is currently under way to prove that this drug in fact works better than a placebo. 

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Botox has been shown to relieve migraine headaches in another two studies published in Headache.  One study compared the efficacy of Botox and an epilepsy drug, Depakote and found them to be equally effective.  However, Depakote caused more side effects, which resulted in more patients taking Depakote dropping out of the study.  The second study was done in patients who had difficulty complying with daily preventive medications.  Half of them were injected with Botox and the other half with saline water.  Neither the doctor nor the patient knew who received which treatment (double-blind study).  The impact of migraines on patients’ lives was significantly improved by Botox.  These two studies by leading headache specialists provides additional proof that Botox is effective for the relief of migraine headaches.

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

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

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

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This is a common question people ask when we suggest that they start taking a daily preventive medication.  A groundbreaking study just published by Hans-Christoph Diener and his colleagues answers this question.  Over 800 patients were placed on topiramate (Topamax), a popular epilepsy drug used to treat headaches.  After 26 weeks half of the patients were switched to placebo and the other half contined on Topamax for another 26 weeks without doctors or patients knowing who was taking what.  It turns out that stopping Topamax did worsen headaches, but not that much – in a 28-day period those on Topamax had one fewer day with migraine than those on placebo.  This suggests that what most headache specialists have suspected from their experience all along is correct.  That is many patients can stop taking their daily medication after about six months without significant worsening.  However, there are some patients who may need to stay on a medication for longerer periods of time.

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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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Postpartum headaches are very common and are usually benign. A study presented at the meeting of the Society for Maternal-Fetal Medicine by Dr. Caroline Stella and her colleagues looked at 95 women with severe headaches that started 25 hours to 32 days after delivery and were not responsive to usual doses of pain medicines. Half of these women eventually were diagnosed to have migraine or tension-type headaches and they all responded to higher doses of pain drugs. In one quarter of patients headaches were due to preeclampsia or eclampsia and were relieved by intravenous magnesium or magnesium and high blood pressure medications. Fifteen women had spinal headaches due to complication of epidural analgesia and they responded to a “blood patch” procedure. Only one woman had a brain hemorrhage and one had thrombosis (occlusion) of a vein in the brain. The authors suggested that all these conditions should be considered when evaluating women with postpartum headaches and appropriate testing needs to be performed.

In another study presented at this meeting Dutch researchers found that women who suffered from an episode of eclampsia had persistent cognitive dysfunction 6-8 years later. This contradicts the widely held belief that women with eclampsia can expect full recovery. This study suggests that eclampsia needs to be treated early and aggressively (magnesium infusion is one of the main treatments) to prevent permanent brain injury. It is also important to understand that persistent cognitive dysfunction is not psychological in nature and that it should be treated with cognitive rehabilitation.

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