DOCTORS' BLOG

 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.”

The pharmacologic treatment of migraine may be acute (abortive) or preventive (prophylactic), and patients with frequent severe headaches often require both approaches. Preventive therapy is used to try to reduce the frequency, duration, or severity of attacks. The preventive medications with the best-documented efficacy are amitriptyline, divalproex, topiramate, and the beta-blockers. Choice is made based on a drug’s proven efficacy, the physician’s informed belief about medications not yet evaluated in controlled trials, the drug’s adverse events, the patient’s preferences and headache profile, and the presence or absence of coexisting disorders. Because comorbid medical and psychologic illnesses are prevalent in patients who have migraine, one must consider comorbidity when choosing preventive drugs. Drug therapy may be beneficial for both disorders; however, it is also a potential confounder of optimal treatment of either.

Children and adolescents experience headaches as do adults and usually present with migraine and chronic daily or tension-type headaches. As some adolescents are unable to achieve headache relief after various treatment strategies, botulinum toxin type A (Botox) injections as a clinical treatment are availabe in selected cases. Botulinum toxin type A by injection has been found to be effective in the treatment of headache disorders in adults. A recent study treated 12 adolescents (aged 14 to 18 years) with Botox injections for migraine and chronic daily headache. Six patients (all female adolescents) were in long-term treatment and received Botox in the standard “migraine” and “follow-the-pain” patterns every 3 months. Effectiveness was evaluated using pain scales and a standardized quality-of-life survey at baseline and prior to each treatment session. Duration of treatment was 3-29 months. Each patient had 9-63 (average = 42) injections per treatment. All 6 long-term patients reported improvement in headache symptoms, with decreases on pain scales and an average of 33%-75% improvement in quality of life. Two long-term patients had complete relief of headaches between injection series. Four patients had only one series of injections with good results. Two patients had no improvement and refused additional injections. Consequently, Botox may be an effective treatment option for certain adolescents with intractable migraine and chronic daily headaches.

Migraine is a common and disabling brain disorder with a strong inherited component. Because patients with migraine have severe and disabling attacks usually of headache with other symptoms of sensory disturbance (eg, light and sound sensitivity), medical treatment is often required. Patients can be managed by use of acute attack therapies (eg, simple analgesics or non-steroidal anti-inflammatory drugs) or specific agents with vasoconstrictor properties (ie, triptans or ergot derivatives). Preventive therapy is probably indicated in about a third of patients with migraine, and a broad range of pharmaceutical and non-pharmaceutical options exist. Medication overuse is an important concern in migraine therapeutics and needs to be identified and managed. In most patients, migraine can be improved with careful attention to the details of therapy, and in those for whom it cannot, neuromodulation approaches, such as occipital nerve stimulation, are currently being actively studied and offer much promise.

A  study conducted by The University of Helsinki, Finnish Institute of Occupational Health and University College London, examined whether work stress, as indicated by the effort-reward imbalance models, predicts onset of newly diagnosed migraine in a cohort of female public sector employees.

The effort-reward imbalance model is a more recent stress model that focuses on a negative trade-off between ‘costs’ and ‘gains’ at work. According to this model, lack of reciprocity between effort spent on work and rewards received in return in terms of money, esteem, security and career opportunities leads to emotional distress that increases the risk of negative health consequences.

In the population studied, 6.2% of the new migraine cases detected were attributable to high effort-reward imbalance, suggesting a modest, rather than strong association between effort-reward imbalance and migraine. Although the increased risk was small, the fact that this potentially modifiable exposure is common means that attempts to find a better balance between personal efforts and rewards gained from work could reduce the burden of migraine in the workplace. However, this will be the case only if the association between effort-reward imbalance and migraine is causal.

These results provide a justification for further research to determine whether effort-reward imbalance may function as a potentially modifiable risk factor for incident migraine.

Chronic daily headache (CDH) is a common problem, affecting approximately 3 to 4% of the population. CDH poses a significant therapeutic challenge to both physician and patient.

For those with moderate or severe CDH, preventive medications are often utilized in an effort to limit analgesics and decrease headache frequency and/or severity. The primary first-line preventives include antidepressants (primarily selective serotonin reuptake inhibitors and tricyclics) and anticonvulsants. Antidepressants have been an attractive choice in those with comorbid depression and anxiety. Tricyclic antidepressants have been known to have enhanced efficacy of SSRI’s, but are not as well tolerated. The anticonvulsants sodium valproate and topiramate have emerged as effective drugs for use in CDH.

In our current study, only 46% of the patients obtained significant long-term relief from a preventive medication. While there are a variety of preventive medications available including, but not limited to, sodium valproate, antidepressants, beta blockers, muscle relaxants, NSAIDs, gabapentin and topiramate, many patients cannot tolerate these medications or find that efficacy is lacking. Among those who do benefit, side effects such as weight gain and fatigue may, over time, cause them to discontinue the medication. The patient may also experience a decline in efficacy over time. Most of the new breakthrough medications have been in the abortive category—particularly the triptans.  Currently there is a lack of new or novel headache preventives.

Many medications have been utilized in an effort to decrease severity and/or frequency of CDH. Short-term (less than six month) studies often demonstrate success at preventing CDH. However, the long-term success of these medications for CDH has not been demonstrated. In fact, while antidepressants and anticonvulsants demonstrated reasonable long-term efficiency, the majority of patients do not obtain adequate long-term relief from CDH preventive medications.

There is a lack of agreement between the results of short-term studies and those which we observed anecdotally regarding long-term success of daily preventive medications.  We need longer-term studies, at least nine to twelve months in length, in order to adequately evaluate the daily preventives. In addition, we need a new approach to more effective daily preventive medications for chronic daily headache.

Outpatient Treatments for RCM

New Technologies and Pharmacotherapies

There are a number of therapeutic options for RCM (Refractory Chronic Migraine), including inpatient treatment. New approaches such as transcranial brain stimulation (TMS), are in various stages of development and will come along. TMS has the potential to alleviate RCM without side effects. There is currently one newer type of TMS machine in use in the US, The Neurostar machine. It is FDA-indicated for the treatment of depression. There is another type of TMS unit in development by the company Neuralieve, which will be primarily used as a migraine abortive. It has the advantage of being readily available in a patient’s home.

Occipital nerve stimulation has been beneficial for a small number of RCM patients. Techniques of implantation have improved but the technical challenges need to be overcome; the leads tend to migrate away from the occipital nerve, for example. Other implantable stimulators are being studied, such as the Bion microstimulator and the Precision Implantable Stimulator for Migraine. It is too early to know what, if any, role these will play.

In pharmacology, there are a number of emerging compounds that may eventually come to market. These include newer abortives, such as 5-HT   drugs.  These work on the 5-HT F receptor, while the current triptans target B and D. CGRP antagonists, such as olcagepant and telcagepant, may be very useful. Gap junction blockers at the neural-glial level are being assessed. Finally, glutamate receptor antagonists are currently in Phase III trials.

Migraine with and without aura is associated with an increased risk of both cardiovascular disease (CVD) and risk factors for CVD, according to an analysis of data from the American Migraine Prevalence and Prevention study.

In an accompanying editorial, Dr. Hans-Christoph Diener with the University Duisburg-Essen and Dr. Judith Harrer with the Department of Neurology at Caritas Klinik St.Theresia in Germany agreed with the study authors that the analysis was limited by certain factors, including a lack of in-person assessments and an inability to control for certain risk factors.

Regardless they remarked that certain conclusions could be drawn from the findings. In particular, they noted, these data suggest that the absolute risk of vascular events in patients with migraine is small, and that such patients should be counseled with absolute rates rather than increases in relative risk.

In addition, they wrote, the increased prevalence of CVD risk factors among the patients with migraine in this study undermines the perception that patients with migraine lead relatively healthy lifestyles, while the data as a whole suggest that vascular risk factors in these patients should be assessed and appropriately treated.

Few physicians are enthusiastic at the prospect of prescribing opioids for the treatment of acute or chronic pain, and for a variety of reasons, there has existed a particular bias against the use of these medications amongst clinicians who subspecialize in headache medicine.  Whatever inherent bias an individual physician harbors against the prescription of opioids may be reinforced by the very real potential for addiction associated with thisclass of drugs, “drug seeking behavior” exhibited by patients in one’s own practice and the concern that opioid therapy both may obstruct the efficacy of more conventional headache treatments and produe an unfavorable long-term outcome.

As many as 8 million Americans suffer from chronic migraine, and not surprisingly it is this segment of the migraine population that suffers the greatest migraine-related disability and accounts for a disproportionate share of the direct costs attributable to migraine diagnosis and treatment.  Clinicians who seek to treat chronic migraine must do so with an arsenal virtually bare of evidence-based therapies.  Preliminary data suggest that patients with chronic migraine may become significantly less likely to respond to therapeutic intervention if they have been experiencing daily headache for 6 months or more.

The argument in favor of considering methadone for patients with chronic migraine who have failed to respond to more conventional treatment interventions includes: 1) treatment-refractory chronic migraine is common, and any clinician whose practice is focused on headache regularly will be confronted with patients so afflicted; and 2) if these patients have failed the more commonly used prophylactic therapies, the options for management would appear to be between a) prescribing a nonopioid prophylactic therapy that is unlikely to prove efficacious b) prescribing symptomatic medication only c) referring the patient to an inpatient headache treatment center or d) prescribing a long-acting opioid (preferably methadone) for chronic headache suppression.