In-Focus: Headache and Migraine
At the recent Fall Meeting of the American Academy of Neurology (AAN) in Las Vegas, Charles Flippen, MD, Associate Professor of Neurology at the UCLA David Geffen School of Medicine, presented an update on recent developments in headache medicine and research. Among the many topics he discussed, Dr. Flippen highlighted the unique challenges migraines present to patients. “Migraines are more than just a headache,” said Dr. Flippen. “The headache brings people in the door, but equally disabling are associated symptoms of nausea, vomiting, and intolerance of ambient environment,” he noted. Not equally recognized are the presence of comorbid conditions, such as bipolar disorder, depression, and IBS, according to Dr. Flippen. “Carrying the burden of migraine along with the added burden of comorbid conditions can make life miserable for patients,” he said. For these reasons, neurologists must consider comorbid conditions within a total treatment plan in order to address the needs of patients with migraines, according to Dr. Flippen.
Dr. Flippen also addressed the topic of alternative medicine in headache management. “Most patients are using some kind of complementary or alternative medicine whether they tell you or not,” he offered. In fact, according to Dr. Flippen, roughly 82 percent of patients are using these medications. Yet, although many of these agents are not studied rigorously, Dr. Flippen acknowledged that some alternative medicines can be used to augment the effects of pharmaceutical agents. Moreover, he noted, they can become key aspects in some patients’ treatment paradigm. “In particular, nutraceuticals can offer a nice way of transitioning to everyday use of pharmaceuticals,” Dr. Flippen said.
Riboflavin: Effective for Adults with Migraines, Not Children
Riboflavin (Vitamin B2) is both safe and well-tolerated for preventing migraine symptoms in adults, findings from a recent review suggest. Since low vitamin B2 can lead to mitochondrial dysfunction and may have an effect on migraine pathogenesis, researchers reviewed evidence regarding the effects of riboflavin (vitamin B2) supplementation on migraine prophylaxis in adults and children. Reviewing data from medical databases between 1990 and 2013, they identified several studies looking riboflavin treatment in both adults and children. Results indicated that supplementation with vitamin B2 in adults can play a positive role in reducing the frequency and duration of migraine attacks with no serious side effects. However, they also noted that there is insufficient evidence to make recommendations regarding vitamin B2 as an adjunct therapy in adults and children with migraine.
—Int J Vitam Nutr Res. 2015; 85(1-2): 79-87.
IS Deep Brain Stimulation Viable for Headache?
Deep brain stimulation (DBS) could potentially offer relief to patients with cluster headache. For a new report, investigators examined the use of DBS for the treatment of headaches since 2000, identifying 79 patients suffering from various forms of intractable short-lasting unilateral headache forms, “mainly trigeminal autonomic cephalalgias.” They found that, after a mean follow up of 2.2 years, 69.6 percent of hypothalamic-stimulated patients showed greater than 50 percent improvement. While the findings are encouraging, the authors stressed that randomized controlled trials are needed to determine the potential value of hypothalamic stimulation as a means of treating headache. The investigators also said that because of its invasiveness, DBS should only be considered after less invasive neurostimulation procedures have been tried.
—Cephalalgia. Dec 7, 2015
Mixed Results in New Review of Oxygen Therapy for Migraine, Cluster Headaches
Hyperbaric oxygen therapy (HBOT) may represent an effective modality for treatment of acute migraines while normobaric oxygen therapy (NBOT) may be beneficial for cluster headaches, according to a new study. “Hyperbaric oxygen therapy is the therapeutic administration of 100% oxygen at environmental pressures greater than one atmosphere, while normobaric oxygen therapy is oxygen administered at one atmosphere,” the study authors wrote. They updated a previous review study published in 2008 with additional trials. Pooling data from three trials, the authors noted that there was no evidence that HBOT could prevent migraine episodes, reduce the incidence of nausea and vomiting, or reduce the requirement for rescue medication. Additionally, there was no evidence that HBOT was effective for the termination of cluster headache. However, they observed that NBOT was effective in terminating cluster headache in a single small study. They found that the proportion of responders was consistent across these three trials, and suggested more than 75 percent of headaches were likely to respond to NBOT. No serious adverse events during HBOT or NBOT were reported.
Given the cost and poor availability of HBOT, the authors recommended that more research be done on patients unresponsive to standard therapy. As for NBOT, they noted that the modality is cheap, safe, and easy to apply and thus will probably continue to be used despite the limited evidence. n
—Cochrane Database Syst Rev. Dec 29, 2015
LETTER TO THE EDITOR
Hemicrania Continua: A Headache Less Common
Hemicrania continua is a rare headache disorder that can be very difficult to diagnose. In the January/February 2012 edi- tion of Practical Neurology® magazine (available online at www. practicalneurology.com), editorial board member Randolph W. Evans, MD authored an article describing the incidence, diagnosis, and treatment options for this condition. Recently, Dr. Evans saw a patient with the condition who had discov- ered his article online. Following is a letter to the editor from the patient, who describes his experi- ence with hemicrania continua:
I had a continual headache from mid July that felt like a sinus infection concentrated on the left side. I had tried acetaminophen to no effect and found that the only analgesic that had any effect was ibuprofen which would reduce the most intense parts of my headache to just manageable levels. I was diagnosed in late August by my Neurologist with migraine and rebound headaches from the analgesics. I argued strongly that this was no migraine but was not listened to and prescribed Axiom and told to stop all pain medication. Like a good soldier I stuck it out for 5 days as my condition deteriorated with the lack of the ibuprofen. I had a constant moderate headache with episodes of excruciating pain. I phoned the Neurologist to say the axiom was not working and she prescribed valproic acid. Five more days of hell over the Labor Day weekend and I was at my breaking point. The episodes were growing in intensity and frequency and I was at my wit’s end!
In between the bouts of excruciating pain I used my software engineering skills to diagnose myself as a piece of errant software running on a rather sophisticated computer. I entered my symptoms carefully and as concisely as I could into Google and came back with a few articles. After dismissing the main primary headaches which really didn’t fit the bill although I pondered cluster headaches briefly I came across Dr. Randolph Evans 2012 article on hemicrania continua in Practical Neurology. The article read like it was written about me, all the way from feeling sand in my eye, congestion in my nostril, tearing through to the exacerbations all unilaterally on my left side. This was it! There was not a shadow of doubt in my mind!
On the Tuesday after Labor Day my wife who is an ex Nurse and very formidable camped out on my Neurologists phone and demanded indomethacin which is both the diagnostic tool and treatment for hemicrania continua. Five or 6 phone calls later the prescription was ordered. That evening I took my first dose of indomethacin and fell asleep with the headache felling slightly better. I woke up a couple of hours later and the headaches were completely gone!
My Neurologist claims her initial diagnosis was correct but we know different, don’t we?
I think my Neurologist suffered from what we in software engineering would call “technical arrogance” which occurs when you let your own preconceptions get in the way of the facts in front of you and the cure for this is to take a few steps back and look at the presented facts logically and without and preconceptions or assumptions.