DOCTORS' BLOG

A recent article in The New York Times debunks the theory that all children are intrinsically good until influenced otherwise. The notion that they are mere products of their environment, and if there is chronic bad behavior, there must be a parent behind it is being challenged. Dr. Richard A Friedman, a professor of Psychiatry at Weill Cornell Medical College in Manhattan, states, “for better or worse, parents have limited power to influence their children. They should not be so fast to take all the blame-or credit-for everything that their children become. The fact remains that perfectly decent parents can produce toxic children”.

Interestingly, little has been written about the paradox of good parents with toxic children. Dr. Friedman continues that we “marvel at the resilient child who survives the most toxic parents and home environment and goes on to a life of success. Yet the converse–the notion that some children might be the bad seeds of more or less decent parents–is hard to take”. The reality is that character traits, like all human behavior, have hard-wired and genetic components that cannot be molded entirely by the best environment, let alone the best psychotherapists. Dr. Theodore Shapiro, a child psychiatrist at Weil concurs; “The era of ‘there are no bad children, only bad parents’ is gone.”

Cervicogenic headache is technically a headache by definition yet its origin is in the neck Frequently, it is combined with neck pain to a varying degree and occasionally, even arm pain of a non-radicular type.

An article in Headache Quarterly by Doctor Otto Sjaastad, Professor Emeritus of Neurology, Trondheim, Norway, discusses terminology of cervicogenic headaches and the misunderstandings with the definition of the term. A headache indicates an ache in the head, and not an ache in the neck-a nuchalgia. An ache felt in the head, but originating in the neck is cervicogenic. Cervicogenic headache is a concept with a solid content, and the term is intimately linked to its contents.

A revised edition of the definition is being prepared. In its most typical recognizable form, it is unilateral in the sense that there is no real side shift. The one side is always involved, either completely alone or with varying of contralateral involvement, but never with only a contralateral pain or predominance of such.

Cervicogenic headache is not defined as a vertebral disorder. It is a common misunderstanding that cervicogenic headache is only caused by disorders at the C2/C3 levels. Disorders at all cervical levels may cause cervicogenic headache. It is not an entity or a disease; it is a syndrome with a number of subgroups .

Headache is a common disease, with 21% of men and 36% of women reported as sufferers in Germany. While in most cases it is sufficient to treat headaches, a significant minority of patients with migraine need interval treatment as attacks occur too often or are insufficiently controlled.

A study in Germany was conducted to assess cost-effectiveness of acupuncture in addition to routine care for headache sufferers. This study was conducted at the Institute for Social Medicine, University Medical Centre in Berlin, Germany.

In this randomized, controlled trial, 3200 patients diagnosed with primary headache were studied during a 3 month period. In these 3 months, costs considered included direct health care costs of acupuncture, physician visits and hospital stays, and any drugs prescribed. Indirect costs caused by lost workdays were also taken into account.

Based on the findings of the study, the specialists determined that acupuncture is a cost-effective treatment for headaches. A quality of life assessment given at baseline and at 3 months further supported positive feedback from acupuncture with highly significant differences in favor of acupuncture-treated patients.

According to a 2009 study, individuals who experience chronic migraine (CM) often have significantly lower levels of household income and are twice as likely to suffer from conditions including depression, anxiety and chronic pain.
It has long been established that CM can be an especially disabling and burdensome condition. Both clinical and population based studies have demonstrated that CM, in comparison with EM (episodic migraine), results in greater migraine-related disability, and impairment in headache related quality of life.
This study, conducted by Dr. Dawn C. Buse and associates at the Montefiore Headache Center in New York, included 24,000 headache sufferers, comparing CM (15 or more headache days per month) and EM (14 or fewer headache days per month) sufferers. Dr. Buse’s findings showed multiple conditions were more common in the CM population including psychiatric (depression, anxiety, bipolar disease), respiratory (allergies/hay fever, asthma, COPD, sinusitis), cardiovascular and related risk factors: (angina, high cholesterol, obesity) and chronic pain. In fact, depression, chronic bronchitis, and ulcers were approximately twice as likely and chronic pain was 2.29 more likely in CM patients compared to EM sufferers.
The differences in the profiles between the two groups imply that CM and EM deviate not just in the degree of headache frequency but in these other important areas. These differences might provide important clues to further explore the differences between CM and EM. It is important for clinicians to maintain diagnostic vigilance and provide appropriate treatment or referrals when necessary.

This study of Repeater Phenomenon in Migraineurs included 465 migraine patients and was conducted by Veronica Villani, MD and colleagues at the “Enzo Borzomsti” Pain Center in Rome, Italy.
Headache is one of the most common symptoms in an emergency department (ED), while migraine is the most frequently observed headache in this setting.
All patients in this study underwent the Migraine Disability Assessment Scale for evaluation of migraine disability, in addition to the Beck Depression Inventory and other assessments for evaluation of depressive, anxiety and alexithymic symptoms (inability to identify and express emotion). According to Norman S. Lumley, MA (Psychosom Med) subjects with alexithymia may be more likely to seek the help of a physician for the treatment of physical signs and symptoms, which may largely explain the repeater phenomenon in our migraine patients.
The data from the study reveals that the personality of repeater migraine patients is characterized by HA behavior, a personality profile that indicates cautious, tense, apprehensive, fearful, and inhibited behavior, as supported by CR Cloninger, detailing a systematic method for clinical description and classification of personality variants (Arch Gen Psychiatry).
The repeater migraine is a complex phenomenon both from a clinical and personality point of view. The repeater migraine patient is characterized by alexithymic and harm avoidance behavior associated with a depressed and anxious state. Clinical aspects, and, or the psychological pattern, may predispose migraine subjects to multiple ED admissions and may, at the same time, be one of the main causes of undiagnosed migraine.
It is important for the HC and the ED to work in close collaboration to provide a correct diagnosis and specific therapy for this unique group of migraine patients. This network may also insure a proper follow-up, with the final outcome being a decrease in migraine disability and health care resource use and expenditure.

A recent study published in Neurology Update suggests transcranial magnetic stimulation (TMS) to be a viable therapy for acute migraine. This study, funded by Neuralieve, Inc., included 201 migraine sufferers. Half of the participants were given the portable TMS device, with the other half receiving an identical sham-stimulation device. All were instructed to use the device to treat as many as three episodes of migraine with aura during a three month period, and to initiate treatment as soon as possible and one hour after aura onset.
The primary outcome of the study was the proportion of patients with a pain-free response during the first migraine episode. 39% of the TMS group was pain free at 2 hours, compared to 22% of sham group. Analysis of secondary efficacy endpoints indicated TMS had significantly higher rates of sustained pain-free response at 24 hours (29% vs 16%) and 48 hours (27% vs 13%) post treatment Additionally, TMS users recorded lower rates of photophobia, phonophobia, and nausea than the sham group.

A study was conducted to describe the consulting behavior and clinical outcomes of children, aged 5 to 17, presenting with headache in primary care. These headaches were described as migraine, tension-type headache, cluster headache or headache with no further descriptor.

The impact of headache on the quality of life of sufferers is significant both at school and at home. Headache has a high risk of persisting into adulthood. The needs of adult headache sufferers are often unmet, and the situation may be worse in the pediatric population, where sufferers are less likely to articulate their problem or seek help. Little is understood about current practice in managing headache in children.

The incidence of brain tumor, a major concern for parents, patients and practitioners, is very low, particularly if headache is the primary diagnosis. However, children with headache have higher levels of anxiety and depression and demonstrate different behavioral characteristics when compare with children not having headache.

Cases receiving a diagnosis of migraine were examined for specific migraine treatment in subsequent year. Drugs were identified that were most likely to be used exclusively for the management of migraine. For the acute attack nasal sumatriptan is the only licensed triptan in the age groups studied.

It is important to identify, diagnose and treat the headache once more serious causes have been excluded. Research is needed to explore why General Practitioners find difficulty in diagnosing headaches, particularly in the younger age group, and to develop strategies to facilitate diagnosis. GPs should be encouraged to make a positive diagnosis in their headache patients as the first step to successful management.

A study in nearly 70,000 pregnant women has found no link between migraine drugs called triptans and the risk of birth defects.

Triptans are among the most powerful drugs used for migraine; others include aspirin, Excedrin, and ibuprofen.

The study, conducted by Katerina Nezvalova-Henriksen of the University of Oslo in Norway, noted that while as many as three in 10 women may develop migraines during their childbearing years, women often shy away from using such drugs during pregnancy because of safety concerns.

The study found that the percentage of birth defects was the same for those who took triptans during pregnancy as those who were not migraine sufferers: 5 percent.

The authors of the study noted, “While it is important to exert caution when using any medications during pregnancy, this study indicates that pregnant women can either start or continue taking triptans without “any major risk” of miscarriage, premature delivery, or other bad outcomes”.

However, the researchers did find that women who used triptans in their second or third trimester were more likely to develop a condition called atonic uterus, in which the uterus fails to contract back to its normal size after delivery. They were also more likely to lose significant amounts of blood during labor and delivery.

Many women who suffer from migraines will experience improvements in their symptoms after their first trimester, Nezvalova-Henriksen and her team note, yet those whose symptoms don’t improve by then aren’t likely to get better.

“Although the findings are reassuring, confirmation in independent studies is warranted,” the researchers conclude.

 Migraine headaches frequently are characterized by symptoms such as nausea, dull or severe head pain and sensitivity to light.

In some sufferers, certain foods may help trigger migraines. The U.S. National Library of Medicine offers this list:

• Processed, marinated, fermented or pickled foods.
• Baked goods.
• Chocolate or dairy foods.
• Foods that contain MSG (monosodium glutamate).
• Foods that contain tyramine, including red wine, aged cheese, smoked fish, chicken liver, figs or certain beans.
• Citrus fruits, bananas or avocados.
• Processed meats containing nitrates, such as hot dogs, salami or bacon.
• Onions.
• Nuts or peanut butter.

Researchers believe they know why light exacerbates the already debilitating pain of migraines, even in some blind people.

A report published in Nature Neuroscience reveals how visual and pain pathways in the brain converge to produce this phenomenon.

The Boston-based researchers report there are cells in a part of the brain called the thalamus “where information from the visual system and information from the pain system converge, and that anatomic convergence provides the first available explanation for how it could be that light makes pain worse,” said Dr. Richard Lipton, director of the Montefiore Headache Center and professor of neurology and epidemiology at Albert Einstein College of Medicine in New York City.

According to the study, about 85 percent to 90 percent of all migraine sufferers report having photophobia, which is when light makes the pain worse.

To solve the paradox, the team studied 20 blind individuals, all of whom suffered from migraines. Six participants had no light perception at all and no functioning optic nerve. These individuals also experienced no photophobia.

The remaining 14 people could sense light and dark and also experienced photophobia.

The study showed that the optic nerve is critically needed in order to produce photophobia or exacerbation of the headache by light.

Senior author Rami Burnstein, a professor of anesthesia and neuroscience at Harvard University, said the study “identified a new pathway in the brain that originates in the eye and goes to the brain areas where neurons are found that are active during migraine attacks. The light can increase the electrical activity in neurons that are active to begin with.”

The findings should put to rest any thoughts that patients exaggerate their sensitivity to light, Lipton said. “This provides an anatomic and physiological basis for a common experience — that light makes pain worse, not because you’re a whiner, but because there is an anatomic pathway that links the visual system to the pathway that produces head pain.”