Posts by ericb

MIGRAINE AND HEADACHE DIETS.


Posted By on Sep 10, 2021

Last updated on September 17th, 2021 at 04:52 am

MIGRAINE AND HEADACHE DIETS.

@Neuralgroover

The best migraine diet is…

 

Well first, there are many well established migraine triggers. The beverages and foods that we consume play a role in headaches and migraines for many patients. In fact, about 10% of headache and migraine sufferers can attribute at least a small part of their headaches to food and diet triggers. Often the trigger is a specific type of food or beverage. For example, in some studies (seen here and here) migraineurs reported their most common food triggers as chocolate (19-22%), cheese (9-18%), citrus fruit (11%), and alcohol (29-35%).

 

Certain types of diets may help reduce the likelihood and severity of headaches and migraines. Let’s take a look at some of the diets out there that may help with headaches and migraines.




How Does the Keto Diet Impact Headaches and Migraines?

The keto diet is unique in the sense that your body consumes more fat and protein while lowering the intake of carbohydrates. The idea is that your body is forced to burn fats rather than carbohydrates. Studies have shown that the keto diet was able to significantly reduce migraine frequency and abortive medication intake. It is thought that the keto diet can be particularly helpful for migraine sufferers on a twofold front:

  1. Ketone bodies produced by the liver can provide the brain with more energy than glucose.
  2. Additionally, ketones are thought to be anti-inflammatory. Since inflammation is a central piece of migraines, the keto diet can potentially help by reducing inflammation.

 

For those who are starting out fresh on the keto diet, there may be an occasional headache since the body is learning to burn fat instead of sugar. To avoid these headaches early on in the keto diet, the following suggestions will help:

  • Drink plenty of water.
  • Eat low-carb, water-rich vegetables.
  • Eat foods that are rich in electrolytes.
  • Avoid exercise on the opening days of your keto diet.

 

Can a Low-Histamine Diet Help With Headaches and Migraines?

Histamine can be a headache or a migraine trigger for certain individuals, even if they do not have allergies. The body makes a digestive enzyme called DAO (diamine oxidase) that processes histamine. About 25% of people have an issue with DAO production in their bodies. One study found that about 87% of people with migraines also had issues with DAO deficiencies. It was found that people who participated in a low-histamine diet had improved in their overall experiences with their migraines while a handful of people in the study had no migraines or headaches at all.

 

What can you eat on the low-histamine diet? You can eat fresh meat (especially chicken) and freshly caught fish. Some non-citrus fruits are low in histamine levels and include things like apples, raspberries, blueberries, melons, bananas, and kiwi. Eggs are also low in histamine. Gluten-free grains, such as rice and quinoa are also low in histamine. Fresh vegetables other than tomatoes, avocados, spinach, and eggplant are also low in histamine levels. Lastly, if you cook with oils, olive oil is low in histamine levels.

 

Elimination Diet, Headaches, and Migraines

From a dietary perspective, an elimination diet is any type of diet where you eliminate foods and beverages that you suspect your body does not tolerate well. On the elimination diet for headaches, there are some things that you might want to avoid:

  1. Caffeine and alcohol: These are known to dehydrate the body and cause headaches.
  2. Chocolate and cocoa: These are known to cause headaches. However, you may eat white chocolate.
  3. MSG: This is a flavor enhancing substance known to trigger headaches and migraines. If you want to avoid MSG, you can eat whole foods that have been flavored with natural herbs and spices. On food labels, it is often hidden as other names including glutamate, natural flavor, and partially hydrogenated vegetable protein.
  4. Processed meats: Anything like jerky, cold cuts, and lunch meats should be avoided. You can however eat fresh meats that you prepare yourself. Nitrates and nitrites are the migraine trigger culprits in these types of foods. These are vasodilating agents found in many foods, especially preserved and processed meats such as lunch meats, sausage, smoked foods, pork, bacon, salami, pastrami, hot dogs, corned beef, ham, and bratwurst. So if you have a child that is getting a lot of headaches and migraines, and eats lunch meat for lunch, you may want to look into nitrate and nitrite-free lunch meat options.
  5. Dairy: You should avoid certain dairy foods like aged cheese, buttermilk, sour cream, and yogurt. However, you can eat things like cottage cheese, cream cheese, and American varieties of cheese.
  6. Nuts: Try substituting seeds for nuts.
  7. Fruits: Avoid citrus fruits altogether. You can eat things like apples, peaches, pears, etc.
  8. Some vegetables, like onions, pea pods, and sauerkraut should be avoided. You can eat most leafy green vegetables and water-rich vegetables.
  9. Condiments: You should avoid things like ketchup, mustard, vinegar-based condiments, etc.
  10. Baked goods: Be careful to make sure that anything you eat is gluten-free while you are on the elimination diet for headaches and migraines.
  11. Avoid any artificial sweeteners altogether, like NutraSweet.
  12. Avoid Fermented foods such as sauerkraut, soy products, and pickled foods because they contain tyramine which is a migraine trigger for many patients. Brewer’s yeast also contains a large amount of tyramine. A low tyramine diet can be very helpful for some patients with migraine.

 

Overall, your doctor may advise you to try the elimination diet for a trial period to see if the foods you are eating are contributing to your headaches and migraines. When attempting to figure out what foods to try eliminating, sometimes IgG food testing against food allergens can assist in determining specific foods which may be associated with high IgG levels in the blood (meaning your immune system is reacting against them).




Inflammatory Foods, Headaches, Migraine, and the Anti-Inflammatory Diet

Another way to fight off headaches and migraines is to avoid foods that are known to cause inflammation. For example, sugar and high fructose corn syrup are found in most processed foods and sweets. In some studies, these sweet substances were known to counteract the effects of omega-3 fatty acids, which can help reduce inflammation. Artificial trans fat, vegetable oils, and seed oils can also cause inflammation, leading to headaches and migraines. Refined carbohydrates, prepared meats, and other processed foods can also cause inflammation. In addition to causing headaches and migraines, foods that cause inflammation can cause a wide variety of other issues including high cholesterol, heart disease, obesity, and diabetes.

 

There are other variations of the anti-inflammatory diet which focus on omega fatty acids including the high omega 3/low omega 6 (H3/L6) and low omega 6 (L6) diets. The thinking is based on the fact that omega 3 is anti-inflammatory, whereas omega 6 is more inflammatory and can increase pain. Fast food is often loaded with omega 6 fatty acids, along with many other chemical additives which are often migraine triggers. So the goal is to eat foods with a higher ratio of omega 3 as compared with omega 6. In fact, a recent study showed that eating fish with healthy omega ratios can help prevent migraines.

 

Fish with a healthy omega ratio include tuna (canned in water), wild salmon, swordfish, mackerel, herring, sea bass, anchovies, sardines, cod, and bluefish. Fish with a less healthy omega ratio include farm raised fish and fish canned in oil. Vegetables with a healthy omega ratio include green leafy vegetables, and those with a less healthy omega ratio include beats, carrotos, chard, and parsley. Nuts and seeds with a healthier omega ratio include walnuts, flax and chia seeds. Those with a less healthy omega ratio include almonds, pecans, cashews, and pistachios. Oils with a healthier omega ratio ratio include olive oil and canola oil, while those with a less healthy omega ratio include highly processed oils such as corn, soy, safflower, and peanut oil.

 

Gluten Free Diet (Celiac Sprue)

Celiac sprue is caused by inflammation in the digestive tract, caused by exposure to gluten. Gluten is a protein found in many grains, including barley, wheat, and rye. Thus it is a common ingredient in foods such as pizza, pasta, bread, and cereal. Patients often complain of abdominal bloating and pain, diarrhea, and headache when they eat these foods. Some patients can less commonly have additional neurological symptoms besides headaches, including unsteadiness/imbalance (ataxia), and peripheral neuropathy. Unexplained iron deficiency is common, and liver function tests are sometimes abnormal. 70% of patients with true gluten sensitivity and celiac sprue have been shown to have improved symptoms within 2 weeks of doing a gluten free diet. Many patients get loosely diagnosed or self diagnosed as “celiac disease” or “gluten sensitive”. However, the gold standard diagnosis is made by small bowel biopsy, along with supporting bloodwork. So if there are suspicious symptoms as discussed here, a gluten free diet for 2-4 weeks may be a good consideration to try.

 

Low Fat Diet

Low fat diets have been reported to decrease headache and migraines in some patients. One study looked at patients eating no more than 20 grams of fat per day. It reported significant differences in migraine frequency which went from 6 days to 1 day per month on average, along with significant decreases in migraine severity, duration, and medication intake.

 

Finding What Works Right For You

The various diets discussed above all have one principle in mind, eliminating certain foods from your diet that can cause headaches and migraines. Many of the foods that are mentioned in the diets above that are to be avoided contain Tyramine. This is the substance produced when the amino acid tyrosine breaks down and can cause headaches.

 

Not only will the right diet help you mitigate the frequency and severity of headaches and migraines, but a proper diet can also help avoid certain types of chronic health conditions. Good diet is only part of the formula that will help you reduce headaches and migraines in your daily life. Your physician will also counsel you on good diet and exercise practices to help you with your headache and migraines.

 

In summary, the answer to which diet is the best migraine diet is… there isn’t one. Finding dietary influences on migraine and headache will vary widely between patients and what their migraine may be susceptible to or what it responds to. However, if there are clues to when you get migraines in relation to any of the dietary factors discussed above when you eat meals, it may be worth trying that particular diet or dietary modification for at least 4 weeks. Any dietary changes should always be discussed and approved of with your regular medical doctor first though, to make sure it is safe to try depending on your particular medical history.

 

Regardless of dietary factors, keep in mind that having migraine means that you are wired in a way that migraines can be triggered easier as compared to someone without migraines. You may be able to identify triggers, but many times there may not be a trigger and migraines can just happen because that is the nature of the disorder, unfortunately. So you still want to ensure that you have a good migraine abortive option for when they do happen. Abortive treatments are taken at the onset of the migraine with a goal of lessening the duration and severity of the migraine attack and associated symptoms. Some of these options include NSAIDs, ergots, triptans, neuromodulatory devices, and the gepants (Ubrelvy (Ubrogepant) and Nurtec ODT (orally dissolvable tablet) (Rimegepant)).

 

If the migraines are happening frequently enough, then a migraine preventive treatment should be considered. Preventive migraine treatments are used to lessen the frequency and/or severity of migraine attacks. Preventive treatments include a variety of daily pill medications, CGRP monoclonal antibodies (mAbs) (Aimovig (Erenumab), Emgality (Galcanezumab), Ajovy (Fremenazumab), Vyepti (Eptinezumab)), neuromodulation devices, Botox, Nurtec ODT every other day (1st and only dually approved migraine abortive and preventive), herbal and natural supplements and vitamins, yoga and meditation, and acupuncture and acupressure.




IF YOU HAVE HEADACHE, MIGRAINE, OR FACIAL PAIN AND ARE LOOKING FOR ANSWERS ON ANYTHING RELATED TO IT, A HEADACHE SPECIALIST IS HERE TO HELP, FOR FREE!

FIRST, LET’S DECIDE WHERE TO START:

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR THE LATEST INFORMATION, HOT TOPICS, AND TREATMENT TIPS, VISIT OUR FREE BLOG OF HOT TOPICS AND HEADACHE TIPS HERE. THIS IS WHERE I WRITE AND CONDENSE A BROAD VARIETY OF COMMON AND COMPLEX  MIGRAINE AND HEADACHE RELATED TOPICS INTO THE IMPORTANT FACTS AND HIGHLIGHTS YOU NEED TO KNOW, ALONG WITH PROVIDING FIRST HAND CLINICAL EXPERIENCE FROM THE PERSPECTIVE OF A HEADACHE SPECIALIST.

IF YOU DON’T HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR POSSIBLE TYPES OF HEADACHES OR FACIAL PAINS BASED ON YOUR SYMPTOMS, USE THE FREE HEADACHE AND FACIAL PAIN SYMPTOM CHECKER TOOL DEVELOPED BY A HEADACHE SPECIALIST NEUROLOGIST HERE!

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR FURTHER EDUCATION AND SELF-RESEARCH ON YOUR DIAGNOSIS, VISIT OUR FREE EDUCATION CENTER HERE.

Read More

Last updated on September 17th, 2021 at 04:53 am

VESTIBULAR MIGRAINE, MIGRAINE VERTIGO, DIZZINESS, AND LIGHTHEADEDNESS.

@Neuralgroover

Vestibular migraine has also been called migraine-associated vertigo/dizziness, migraine-related vestibulopathy and migrainous vertigo. Vestibular migraines are not as common as other headache and migraine conditions, but they impact about 3% of the population. They happen five times more often in women than they do in men. One of the common themes among vestibular migraine sufferers is that this condition is often found in their family history, and often, these people have a history of migraines. An early clue can be that they may have gotten easily car sick as a child, and they may still as an adult.

Dizziness, lightheadedness, and wooziness are very common symptoms associated with regular migraine attacks. Vestibular migraines cause severe dizziness, vertigo, imbalance, and disequilibrium in people with migraines. The severity of these symptoms in vestibular migraine are much more severe and pronounced as compared with the more commonly associated milder dizziness type of symptoms often seen with normal migraine attacks. In addition, with vestibular migraine, you might not always have a headache with the symptoms, which can make diagnosis even more tricky. So, let’s dissect the specifics and symptoms of vestibular migraine a bit more below…




What Types of Symptoms Might I Experience With a Vestibular Migraine?

As mentioned above, vestibular migraines don’t always coincide with a headache. They include dizziness that lasts for a few moments or more, nausea, vomiting, balance problems, sensitivity to motion when you move your body, disorientation, and sensitivity to light or sound. Vestibular migraines are connected to the inner ear, so a person experiencing this type of migraine will have significant issues with their balance and equilibrium during an attack.

 

The International Classification of Migraine 3rd Edition (ICHD3) has specific criteria that must be met to fit the diagnosis. Other causes of vestibular symptoms such as inner ear problems and other causes must have been tested for and excluded. The person must have a history of migraine without aura or migraine with aura. They must have at least 5 episodes of moderate to severe vestibular symptoms lasting between 5 minutes to 72 hours. Vestibular symptoms can include vertigo, spinning sensation, sensation of self-motion, disequilibrium, positional vertigo such as following a change in head position or head motion, dizziness with nausea, and visually induced vertigo triggered by a moving visual stimulus. At least half of these vestibular symptom episodes must be associated with 1 of the following 3 migrainous features:

1. Headache with at least 2 of the following 4 features:

  1. One sided location
  2. Pulsating, throbbing, or pounding pain
  3. Moderate to severe intensity
  4. Worsening by physical activity

2. Sensitivity to light (photophobia) and sound (phonophobia)

3. Visual aura

 

Approximately 1/3rd of patients can have vestibular symptoms lasting minutes, 1/3rd can last hours, and 1/3rd can last several days. A small fraction of patients have vestibular attacks which can last seconds only, but occur repeatedly during head motion, changes in head position, or visual stimulation. In these patients, episode duration is defined as the total period during which short attacks are recurring with these triggers. An even smaller fraction of patients can have attacks that can last several weeks to a month. Overall, attacks last 72 hours or less for the vast majority of patients.

 

What Causes Migraines With Vertigo?

The exact cause of vestibular migraines is not clearly understood. However, many researchers believe that there is overlap and erroneous connections between pain signals and vestibular signals that come in from the inner ear and the electrical migraine pathways. Some contributing factors to vestibular migraines include many of the commonly recognized migraine triggers such as lack of sleep, consumption of MSG and certain other foods, and dehydration.

 

How Long Does a Vestibular Migraine Last?

Vestibular migraines can last for a period as short as 5 minutes or up to 72 hours, as detailed above. Some patients have reported this type of migraine lasting for up to 4 weeks, with the intensity of the symptoms coming and going.

 

What Types of Treatments Will Help Alleviate Vestibular Migraines?

Different types of abortive therapies are available for vestibular migraines. Abortive migraine medications are medications taken at the onset of the migraine with a goal of lessening the duration and severity of the migraine attack and associated symptoms. Some of these options include NSAIDs, ergots, triptans, neuromodulatory devices, and the gepants (Ubrelvy (Ubrogepant) and Nurtec ODT (orally dissolvable tablet) (Rimegepant)). Triptans and abortives are particularly helpful if they are taken at the first sign of symptoms. Your doctor might prescribe something like Ativan, Valium or another vestibular suppressant to correct the balance on your inner ear, but these should preferably not be taken frequently or daily because they can form dependency and addiction.

 

Calcium blockers and beta blockers can also work to reduce the severity and intensity of your vestibular migraine, but there are many other migraine preventive options as well. Preventive migraine treatments are used to lessen the frequency and/or severity of migraine attacks. Preventive treatments include a variety of daily pill medications, CGRP monoclonal antibodies (mAbs) (Aimovig (Erenumab), Emgality (Galcanezumab), Ajovy (Fremenazumab), Vyepti (Eptinezumab)),  neuromodulation devices, Botox, Nurtec ODT every other day (1st and only dually approved migraine abortive and preventive),  herbal and natural supplements and vitamins, yoga and meditation, and acupuncture and acupressure.

 

Some of the typical migraine pill preventive medications include antiseizure, blood pressure, and antidepressant drugs. These traditional migraine medications can also be very helpful in treating more severe occurrences of vestibular migraines.




Could My Vestibular Migraine Be Something Else?

Vestibular migraines have symptoms that overlap with other medical conditions. In fact, at least 20% of vestibular migraine cases are misdiagnosed. A condition called Meniere’s disease causes dizziness. This disease, however, will often be accompanied by a stuffed ear sensation or ear ringing. Referral to an ENT doctor (ear nose and throat) to evaluate for inner ear disorders should always be part of the evaluation plan, along with possible neuroimaging with brain MRI or CT, and possibly some blood work. A brainstem stroke can also cause dizziness before more severe symptoms set in. MRIs and other medical tests can help rule conditions like these out. Therefore, vestibular migraine should always be a “diagnosis of exclusion”, meaning it can be considered only after other causes of dizziness and vertigo have been tested for and ruled out.

 

How Will My Doctor Manage My Vestibular Migraines?

In addition to some of the medications suggested above, there are ways to manage your vestibular migraines. Your doctor will probably do a full medical examination to understand any comorbidities and also see what medications you are currently taking. Dizziness is one of the most commonly reported side effects of many medications, so make sure to trace onset of symptoms back to any medication adjustments as well.

Depression, lack of sleep, and anxiety are some of the issues that may be exacerbated by your vestibular migraines. If these conditions are left untreated, the vestibular migraine will not get better. Depression and anxiety do not cause vestibular migraines, but the migraines can lead to anxiety and depression and these issues can all begin to feed into and fuel one another.

Another thing to keep in mind is that traditional medicinal approaches to headaches may not be the best approach to vestibular migraines for everyone. Vestibular migraines can sometimes be sensitive to Advil, Tylenol, and other NSAIDs. However, most patients will not respond as well to these over the counter medications and will need more migraine specific therapies. If you use triptans or NSAIDs daily or with a high frequency of more than 10 days per month on average, you may be more prone to rebound vestibular migraines. Vestibular physical therapy can also be helpful for some patients if they suffer from a high frequency of symptoms.

 

What Is the Outlook for Vestibular Migraines?

Overall, the outlook for Vestibular migraines is good. An NIH study found that vestibular migraines in a pool of patients from a period of 10 years decreased in about 56% of cases, increased in only about 30% of people, and stayed the same in about 16 percent of cases.




IF YOU HAVE HEADACHE, MIGRAINE, OR FACIAL PAIN AND ARE LOOKING FOR ANSWERS ON ANYTHING RELATED TO IT, A HEADACHE SPECIALIST IS HERE TO HELP, FOR FREE!

FIRST, LET’S DECIDE WHERE TO START:

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR THE LATEST INFORMATION, HOT TOPICS, AND TREATMENT TIPS, VISIT OUR FREE BLOG OF HOT TOPICS AND HEADACHE TIPS HERE. THIS IS WHERE I WRITE AND CONDENSE A BROAD VARIETY OF COMMON AND COMPLEX  MIGRAINE AND HEADACHE RELATED TOPICS INTO THE IMPORTANT FACTS AND HIGHLIGHTS YOU NEED TO KNOW, ALONG WITH PROVIDING FIRST HAND CLINICAL EXPERIENCE FROM THE PERSPECTIVE OF A HEADACHE SPECIALIST.

IF YOU DON’T HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR POSSIBLE TYPES OF HEADACHES OR FACIAL PAINS BASED ON YOUR SYMPTOMS, USE THE FREE HEADACHE AND FACIAL PAIN SYMPTOM CHECKER TOOL DEVELOPED BY A HEADACHE SPECIALIST NEUROLOGIST HERE!

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR FURTHER EDUCATION AND SELF-RESEARCH ON YOUR DIAGNOSIS, VISIT OUR FREE EDUCATION CENTER HERE.

Read More

Last updated on September 17th, 2021 at 04:53 am

WHAT ARE THE CGRP MIGRAINE MEDICATIONS AND HOW ARE THEY USED?

@Neuralgroover

What is CGRP (Calcitonin Gene Related Peptide)?

During a migraine attack, the trigeminal nerves release a variety of inflammatory proteins. One of the main proteins is called CGRP (calcitonin gene related peptide). CGRP has been studied since the early 1980s when it was discovered. It was found throughout the trigeminovascular system and trigeminal cranial nerves which transmit pain in the head and face. Therefore, a role in migraine was suspected. The trigeminal nerves are central to causing migraine as explained here. The trigeminal nerves and their associated electrical circuitry throughout the brain, brainstem, and arteries in the brain is called the trigeminovascular system. This system is the basis and an “on switch” for migraine.

In the early 1990s it was shown that CGRP was released by the trigeminal nerves and levels increased during an acute migraine attack. In 2004, a CGRP antagonist (blocks the binding of CGRP to its receptor) was shown to abort (stop) an acute migraine attack, and decrease CGRP levels. Subsequent preventive migraine studies done since 2014 with a CGRP antibody to block the effects of CGRP continued to show reduction in migraine frequency and severity.

 

CGRP causes inflammation around the brain and cerebral arteries (“sterile inflammation”) in the dural membrane surrounding the brain, intensifies pain signals, enhances transmission of pain signals through the trigeminal nerves into the brainstem and into the brain, and causes dilation of the cerebral arteries through the dural membrane. Trigeminal nerve endings surround these arteries. The dilation of these arteries triggers these trigeminal nerve endings and this leads to further increasing pain signals. Think of the process like a painful meningitis, minus the infection.

 

The result of these steps is intense migraine pain (as you are unfortunately very familiar with). So, if we can block these steps of migraine pain, the attack should be aborted quickly, and not as severe. That’s the thinking here, and that’s where the CGRP medications (gepants and CGRP monoclonal antibodies) come into play, as discussed below.

 

CGRP MEDICATIONS USED TO ABORT MIGRAINE (TAKEN AS NEEDED)

Abortive migraine medications are medications taken at the onset of the migraine with a goal of lessening the duration and severity of the migraine attack. Historically, the options have included NSAIDs, ergots, triptans, and neuromodulatory devices.

 

The gepants were the first new medicine class to emerge as new migraine abortive options (FINALLY!!!) since the triptans became available in 1992. There are currently 2 oral pill gepant abortive options available. They are Ubrelvy (Ubrogepant), and Nurtec ODT (orally dissolvable tablet) (Rimegepant). These 2 gepants are discussed and compared in much greater detail here. Zazegepant will be the 3rd abortive gepant, and will be the 1st nasal spray gepant option available. It is in ongoing clinical trials currently.

 

How does Nurtec ODT and Ubrelvy (gepants) work?

Gepants work as CGRP receptor antagonists, which means they directly block (antagonist) the CGRP receptor. This results in the medication “blocking” the CGRP inflammatory protein from sticking to the CGRP receptor to activate it, and thus prevents it from “turning on” the pathways of pain described above.

 

So, you get reversal of cerebral vasodilation, which decreases the firing off of the trigeminal nerves. Notably, the gepants do this in a way that does not cause vasconstriction, in contrast to the triptans. Thus, they are felt to be safe in those with cardiovascular or cerebrovascular disease (as opposed to the triptans).

 

By blocking the CGRP receptor, you also get reversal of the neurogenic inflammation going on through the brain and around the arteries, and you block the electrical transmission of migraine pain from traveling from the trigeminal nerves into the brainstem, and ultimately into the brain.

 

The other huge benefit of the triptans compared to all other abortive options is that they do not cause medication overuse headache (rebound headache)!

 

What are the side effects of Nurtec ODT and Ubrelvy?

The side effect profile of the gepants is minimal and similar to placebo. The most common side effects of gepants are very low risk of nausea for Nurtec ODT and low risk of nausea and mild sedation with the higher dose of Ubrelvy. Side effects are discussed in more detail here.

 

In addition, there is no interaction with using them and triptans, NSAIDs, or other acute meds in case they happen to be taken close together.

 

Compared to other abortive medications such as the triptans and NSAIDS, these medications are not associated with medication overuse headache (rebound headache), which is great! They also have no addiction potential.

 

Compared to the triptans and ergots, these medications are NOT contraindicated in patients with stable cardiovascular or peripheral vascular disease or risk factors because they do not cause vasoconstriction (narrowing) of the arteries, which is a HUGE benefit.

 

Triptans are also contraindicated in patients with visual snow, persistent migraine aura, and migrainous stroke (infarction). However, gepants are felt to be safe for these patients, as well as those with hemiplegic migraine and migraine with brainstem aura (previously called basilar migraine). There are many patients who have been stuck without safe options since they have been unable to use standard therapies such as triptans due to other medical problems such as heart disease. So, we finally have a safe alternative for them, which is a highlight of these medications.

 

Can Nurtec ODT and Ubrelvy be used in pregnancy and breastfeeding?

Safety of these medications in pregnancy or breastfeeding is unknown because they haven’t been studied, and therefore are not recommended.

 

Are there drug interactions with Nurtec ODT and Ubrelvy (gepants) and other medications?

The primary drug interactions to be aware of with these medications are when used with other medications that are metabolized by the liver enzyme system called CYP3A4. Many commonly used medications are metabolized by this system. Strong or moderate inhibitors of CYP3A4 (which slow down the metabolic drug breakdown) will cause an increase in gepant blood levels. Strong or moderate inducers of CYP3A4 (which increase the metabolic drug breakdown) will cause a decrease in gepant blood levels and possibly decreased effectiveness. These medications should be avoided in patients with severe liver disease or end stage kidney disease such as those on dialysis.

CGRP MEDICATIONS USED TO PREVENT MIGRAINE

Preventive migraine treatments are used to lessen the frequency and/or severity of migraine attacks. Preventive treatments include a variety of daily pill medications, neuromodulatory devices, herbal and natural supplements and vitamins, yoga and meditation, acupuncture and acupressure. All of the medications used for migraine prevention have always been “adopted” from other specialties. In other words, these were medicines made for other purposes (such as antidepressants, antiseizure, anti-blood pressure meds), but eventually some were also found to be useful for migraine prevention.

 

There has never been a medicine engineered and created purely and only for migraine prevention. However, that changed in 2018 when the migraine preventive landscape changed abruptly and significantly. The 1st medication class designed purely and only for migraine prevention become available, called the CGRP monoclonal antibodies (mAbs). There are currently 4 CGRP mAb treatment options. They are Aimovig (Erenumab), Emgality (Galcanezumab), Ajovy (Fremenazumab), and Vyepti (Eptinezumab).

 

These medications either target the CGRP receptor (Aimovig), or the CGRP protein (Emgality, Ajovy, Vyepti). The result of “blocking” the CGRP protein or CGRP receptor prevents the CGRP pathways of pain from “turning on”, as discussed above and here. Clinically, some patients tend to respond better to the CGRP receptor blockade, whereas others tend to do better with binding the CGRP protein itself. There is not really any data on this in terms of who may respond to which type of CGRP mAb target, but I’m sure it will be studied further eventually.

 

Aimovig, Emgality, and Ajovy are all once monthly self-injections (push button autoinjection), although Ajovy also has the option of quarterly injections (3 injections every 3 months). Vyepti is the only IV (intravenous form) and is done by 30-minute IV treatment every 3 months. These individual CGRP mAbs are discussed and compared in much greater detail here.

 

What are the side effects of the CGRP mAbs (Aimovig, Emgality, Ajovy, Vyepti)?

Compared to most other medications used for migraine prevention historically, the side effects of the CGRP mAbs are very low. The most common side effects reported (at a very low rate) are mild upper respiratory infections and minor injection site reactions. Aimovig has a slightly increased risk of constipation and possible mild increase in high blood pressure for some patients. These have little to no drug interactions and do not affect the liver or kidneys. Data show no immunological (they do not suppress or alter the immune system because they do not have a target within the immune system), cardiovascular, or neurological safety concerns of significance.

 

Can the CGRP mAbs (Aimovig, Emgality, Ajovy, Vyepti) be used in pregnancy and breastfeeding?

There is no data to answer this question yet. However, CGRP is suspected to play a possible role in regulating uteroplacental blood flow, myometrial and uterine relaxation, and in maintaining normal gestational blood pressure. Since the mAbs have a long half-life and can last in the system for 5 months, it is recommended to stop it about 6 months prior to pregnancy planning. The CGRP mAbs are also not recommended to use during breast-feeding since we do not have enough safety data at this time.

 

Nurtec ODT and gepants for migraine prevention.

The CGRP mAbs have been a major step forward for migraine prevention. However, up to this point, we still have not had an oral pill that has been engineered and created purely and only for migraine prevention (not “adopted” from a different medicine class as mentioned above).

 

That was until now, with development of the gepants (discussed above). On 5/27/21, Nurtec ODT (Rimegepant) made history as the first and only FDA approved medication for BOTH abortive and preventive migraine treatment simultaneously, and the only option with this flexibility and is discussed in greater detail here!

 

The perspective behind this is that migraine is a fluid and variable disease, fluctuating between periods of episodic migraine (1-14 headache days per month), and other periods of chronic migraine (15 or more headache days per month). So, having a medicine that can function as both types of treatment, depending on what type of phase the migraine is in (episodic or chronic) opens up an entirely new flexible treatment paradigm and approach which we have never had up to this point.

 

So essentially, taking Nurtec ODT every other day could be used as an ongoing daily preventive strategy (the long half-life of 11 hours allows for this spread-out dosing) when the migraine is in a high frequency to chronic migraine phase. If it evolves back into a lower frequency episodic migraine pattern, it can then just be used abortively only when needed for a migraine attack.

 

This new flexible dosing option of Nurtec ODT could also be used as a “mini-prophylaxis” within the month. For example, if patients know they are approaching a predictable migraine trigger, such as menstrual migraine, barometric trigger from an airplane trip, upcoming stressful event such as an exam, etc., the medication could possibly be taken daily or every other day starting a few days before the anticipated trigger, and stopping it a day or so after the trigger is no longer present. Unlike other migraine preventive pill treatments which take 4-6 weeks to start working and 2-3 months to see full effect, the gepants work fast and this would allow this potential treatment option to begin working immediately. In fact, studies show that migraine frequency dropped by 30% within the first week alone of preventive use.

 

Atogepant is the 2nd gepant that will be used as a daily preventive pill only and is pending FDA approval, but is anticipated soon.

 

Can the preventive CGRP mAbs (Aimovig, Emgality, Ajovy, Vyepti) be used with the CGRP abortive gepant medications (Nurtec ODT, Ubrelvy)?

Can I use Aimovig with Nurtec ODT? Can I use Aimovig with Ubrelvy? Can I use Emgality with Nurtec ODT? Can I use Emgality with Ubrelvy? Can I use Ajovy with Nurtec ODT? Can I use Ajovy with Ubrelvy? Can I use Vyepti with Nurtec ODT? Can I use Vyepti with Ubrelvy? These are very common questions. Unfortunately, there aren’t many studies so far to clarify this, although I’m sure these questions will be studied and clarified in the near future. The gepants and the CGRP mAbs have much different structures, molecule sizes, and metabolism.

 

So theoretically, it would make sense that using an abortive CGRP medication (gepant) on top of a CGRP preventive medication (CGRP mAb) would give synergistic (working together) benefit. Using a CGRP preventive medication targeting the CGRP protein (Emgality, Ajovy, Vyepti) and a CGRP abortive medication targeting the CGRP receptor (Nurtec ODT, Ubrelvy) seems like a very sensible idea. Similarly, using a CGRP preventive medication targeting the CGRP receptor (Aimovig) combined with a CGRP abortive medication also targeting the CGRP receptor (Nurtec ODT, Ubrelvy) would make a lot of sense too. In fact, there are some limited studies which provide evidence that these medications used together do work better and are safe.

 

There was a publication of data from only a 2-patient cohort showing that the use of these acute and preventive CGRP migraine therapies together can be successful and safe. These two patients had been using Rimegepant (Nurtec ODT) in a long-term safety study and they had added Erenumab (Aimovig) once monthly injection as a preventive treatment. After Aimovig was added, patient 1 had 100% relief for 7 of 7 acute migraine attacks treated with Nurtec. Patient 2 had 100% relief for 9 of 9 acute migraine attacks treated with Nurtec. So, the combination of using Nurtec abortively in addition to using Aimovig preventively appeared to provide an even more effective acute migraine response. Larger studies to confirm the suspicion that they likely work together synergistically will be helpful.

 

There was a larger safety study publication which evaluated the acute treatment of migraine with Rimegepant while using a CGRP monoclonal antibody for the prevention of migraine. The CGRP mAbs used were Erenumab (Aimovig) (7 patients), Fremanezumab (Ajovy) (4 patients), and Galcanezumab (Emgality) (2 patients). The study determined that Rimegepant used as an acute migraine treatment in combination with CGRP mAbs for migraine prevention was well tolerated with no safety issues identified. The researchers concluded that the probability between these 2 classes (gepants and CGRP mAbs) was low, especially because they have entirely different pathways of drug metabolism. The gepants are metabolized in the liver, while the CGRP mAbs are metabolized and cleared in the reticuloendothelial system. They also concluded that existing evidence supports the safety of combined use, although further larger research was warranted.

 

Can the CGRP mAbs (Aimovig, Emgality, Ajovy, Vyepti) be used with Botox (Onabotulinumtoxin A) for chronic migraine?

The answer is yes. Insurance companies often present various hurdles to using preferred treatment options (the bane of my existence). One common issue for patients with chronic migraine who are receiving Botox injections is that most insurance companies will now make the patient choose between Botox or the CGRP mAb. There is of course no good scientific basis for this, other than the company doesn’t want to pay for both.

 

Actually, there is evidence that using Botox with the CGRP mAbs works better together than with either individually. An abstract presented at the American Headache Society Annual Scientific meeting in June 2020 showed that in patients with chronic migraine and a baseline frequency of 25.7 days per month, the frequency dropped to 14.8 days with Botox, and 9.1 days with Botox plus a CGRP mAb.

 

Can I still use my CGRP mAb (Aimovig, Ajovy, Emgality, Vyepti) with the Covid-19 vaccine?

This hasn’t been a reported issue thus far. There is no current evidence for an interaction between the Covid-19 vaccine and CGRP mAbs, the same as any other vaccine. This has also been stated by the American Migraine Foundation. Patients receiving CGRP mAbs were not excluded from the Covid-19 vaccine trials. There is no evidence at this time that these treatments cannot be used along with receiving Covid-19 vaccination, nor do they need to be delayed or timed any differently in relation to receiving Covid-19 vaccination.

 

Most physicians feel that there should theoretically be no interaction or contraindication to receiving either of these treatments in relation to Covid-19 vaccination because they are entirely different proteins with different mechanisms of action. The Covid-19 vaccine stimulates the immune system to form antibodies against the virus, should you encounter it. The CGRP mAbs do not have any significant influence on the immune system (they do not cause immunosuppression, etc.).

 

Rarely, the immune system of some patients can form neutralizing antibodies against the CGRP mAbs, and this can weaken the effectiveness of these treatments in their ability to decrease migraine frequency and severity. However, this rarity really has nothing to do with the mechanism and how the Covid-19 vaccine works. So, it is not felt that the Covid-19 vaccine will lessen the effectiveness of these treatments, nor will these treatments lessen the effectiveness of the Covid-19 vaccine.

 

Notably, there have been just a few isolated reports of dermal fillers used in dermatology causing some facial swelling in association with Covid-19 vaccination, but not with Botox or the CGRP mAbs. These reports were with the Moderna Covid vaccine and resolved with steroids and/or antihistamines. The topic of Covid-19 headache and Covid-19 vaccination is discussed further here.

 

IF YOU HAVE HEADACHE, MIGRAINE, OR FACIAL PAIN AND ARE LOOKING FOR ANSWERS ON ANYTHING RELATED TO IT, A HEADACHE SPECIALIST IS HERE TO HELP, FOR FREE!

FIRST, LET’S DECIDE WHERE TO START:

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR THE LATEST INFORMATION, HOT TOPICS, AND TREATMENT TIPS, VISIT OUR FREE BLOG OF HOT TOPICS AND HEADACHE TIPS HERE. THIS IS WHERE I WRITE AND CONDENSE A BROAD VARIETY OF COMMON AND COMPLEX  MIGRAINE AND HEADACHE RELATED TOPICS INTO THE IMPORTANT FACTS AND HIGHLIGHTS YOU NEED TO KNOW, ALONG WITH PROVIDING FIRST HAND CLINICAL EXPERIENCE FROM THE PERSPECTIVE OF A HEADACHE SPECIALIST.

IF YOU DON’T HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR POSSIBLE TYPES OF HEADACHES OR FACIAL PAINS BASED ON YOUR SYMPTOMS, USE THE FREE HEADACHE AND FACIAL PAIN SYMPTOM CHECKER TOOL DEVELOPED BY A HEADACHE SPECIALIST NEUROLOGIST HERE!

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR FURTHER EDUCATION AND SELF-RESEARCH ON YOUR DIAGNOSIS, VISIT OUR FREE EDUCATION CENTER HERE.

Read More

Last updated on September 17th, 2021 at 06:48 am

HEADACHES THAT OCCUR DURING PREGNANCY.

@Neuralgroover

Many women experience headaches during their pregnancy. In fact, some research has shown that 39% of women may experience some sort of headache or migraine during their pregnancy during their postpartum. The sensation and type of headaches that women experience during their pregnancy may be different, but generally, pregnancy headaches should not raise too much alarm. Generally speaking, many women who suffer from frequent headaches before pregnancy often note that these decrease in severity and intensity because of increased estrogen throughout the body. Menstrual migraines are typically caused by the drop in estrogen prior to the menstrual cycle. So if with a sustained level of estrogen, that trigger is eliminated during pregnancy.

 

For the majority of women (60-70%), migraines improve during pregnancy, particularly in the 2nd and 3rd trimester. It is not uncommon to hear women mention that their migraines were gone during pregnancy. Unfortunately, it is also not uncommon to hear that the migraines come roaring back after delivery and hormonal shifts move back to normal. The women that tend to improve during pregnancy are those that have migraine without aura, migraines related to menstrual cycles, and migraines that began with menarche (when menstrual cycles began). With that said, 4-8% of women have worsening migraines during pregnancy.

 

What Types of Headaches Are Common During Pregnancy and Postpartum?

Primary headaches are the most common type of pregnancy and postpartum headaches. These are primarily migraine and tension-type headache. Some of the symptoms that you may experience as a result of a pregnancy headache or migraine include a dull ache or pressure (tension type headache), a pulsating or throbbing pain (migraine), and a sharp pain around one or both eyes (typically migraine).

 

About 25% of these headaches in pregnant women are tension headaches. Secondary headaches that occur during pregnancy are less common and may be related to circulatory issues such as high blood pressure (pre-eclampsia, eclampsia) and low iron levels. Idiopathic intracranial hypertension (IIH), previously called pseudotumor cerebri, can sometimes also occur or worsen during pregnancy. Less common but serious medical causes could also include cerebral venous thrombosis (blood clot in the large veins of the brain). Any change of headache pattern or new headache development during pregnancy requires an evaluation with your doctor.

 

Pregnancy Headaches By Trimester

Depending upon which trimester you are in, the cause of your headaches and the accompanying symptoms will be different. Hormonal changes, higher blood volume, and weight gain/loss are contributors to headaches during your first trimester. Some of the causes of these headaches might include dehydration, nausea, stress, vomiting, lack of nutrition, low blood sugar, and other issues.

 

During your second and third trimesters of pregnancy, you might have different causes of your headache. Weight gain, posture, lack of sleep, muscle strain and tightness, and other issues are the biggest causes of pregnancy headaches during this period.

 

Throughout your pregnancy there are certain foods that can also cause headaches and be migraine triggers. These include chocolate, dairy products (milk and cheese), anything with yeast, tomatoes, and certain other food items. Caffeine can also increase the likelihood of a headache during your pregnancy.

 

When Should You Worry About Headaches During Pregnancy?

More intense and frequent headaches that happen during your 2nd and 3rd trimesters could be indicative of high blood pressure. This condition is not common and impacts about 8 percent of pregnant women who are between 20 and 44. High blood pressure could cause serious complications for both the mother and child. Preeclampsia, stroke, premature delivery, low birth weight, and preeclampsia or eclampsia odds are higher for pregnant women with high blood pressure.

 

When you have a severe headache during pregnancy that causes dizziness, blurred vision, and other issues, you must see your doctor. If it comes on abruptly, you should see a doctor in the emergency room. Headaches during the 2nd and 3rd trimester with greater frequency and intensity could increase the risk of stroke if they are related to high blood pressure or cerebral venous thrombosis. As mentioned above, any change in your normal headache pattern, or development of new headaches during pregnancy, needs to be discussed and evaluated with your doctor. Some women can develop or exacerbate symptoms of idiopathic intracranial hypertension (IIH), which was previously called pseudotumor cerebri. This is caused by high pressures of the cerebrospinal fluid (CSF) around the brain. Symptoms consist of daily or frequent headaches along with visual disturbances such as blurred vision, persistent areas of lost vision, and frequent brief episodes of visual black outs, grey outs or blurring lasting 5-15 seconds called transient visual obscurations (TVOs).

 

Dealing With Headaches During Pregnancy

You should avoid any known headache triggers, especially certain types of foods. These include MSG, cured meats, strong cheeses, certain dairy products, anything with yeast, and caffeine. Avoid secondhand smoke, as this can cause headaches. Eat well and drink plenty of fluids, which will help reduce morning sickness. When you are pregnant, avoid stress. Massages and cold (or sometimes warm) presses will also help deal with headaches, especially tension headaches. Cool, dark rooms with no noise will help with migraines, as well as other conservative treatments.

 

Abortive (As-Needed) Medications for Headaches and Migraines During Pregnancy

Overall, acetaminophen is fairly safe to take for headaches during pregnancy. Up to the third trimester (32 weeks), NSAIDs are considered safe, as well. After the third trimester (after 32 weeks), ibuprofen and other NSAIDs can put the baby at risk. NSAIDs can cause a serious issue affecting the blood pressure in your baby’s lungs. Additionally, NSAIDs used late in pregnancy cause issues with amniotic fluid and make for an elongated labor.

 

Triptans have historically been avoided in pregnancy due to theoretical concern that their vasoconstrictive (blood vessel narrowing) effects may result in less blood flow to the placenta and baby. However, many physicians are increasingly using triptans during pregnancy now given some evidence suggesting they can be used safely and anecdotal evidence that they appear generally safe, although more research is needed. Some antiemetics are used during pregnancy for not only nausea, but also some abortive benefit. Metoclopramide has generally been felt to be the safest antiemetics and most often used in this scenario. Currently, it is recommended to avoid the gepants (Nurtec ODT and Ubrelvy) during pregnancy and breastfeeding because there is not enough safety data at this time.

 

Preventive Medications for Headaches and Migraines During Pregnancy

Magnesium supplementation is often recommended as a preventive migraine treatment both during pregnancy and outside of pregnancy. Other medications sometimes used for migraine prevention if needed include cyproheptadine (although it should be stopped when breastfeeding starts to avoid sedation in the baby), metoprolol, and some SSRI type antidepressants. Current recommendations are that CGRP monoclonal antibodies (Aimovig, Emgality, Ajovy, Vyepti) are not used during pregnancy or breastfeeding because there is not enough safety data at this time. In addition, CGRP is suspected to play a possible role in regulating uteroplacental blood flow, myometrial and uterine relaxation, and in maintaining normal gestational blood pressure. Since the CGRP mAbs have a long half-life and can last in the system for 5 months, it is recommended to stop it about 6 months prior to pregnancy planning. Historically, Botox has generally been avoided in pregnancy, although some physicians are increasingly using it during pregnancy for refractory chronic migraine.

 

Non-Medication Treatments For Headaches During Pregnancy

There are certain types of non-medication treatments that may also help with headaches and migraines during pregnancy. These include activities and therapies aimed at lowering stress such as mindfulness, relaxation,biofeedback, yoga and meditation, acupuncture, acupressure and pressure points. Sometimes exercise or physical therapy can be helpful. Neuromodulation devices, trigger point injections, or nerve blocks such as occipital nerve blocks can also be helpful. Essential oils are also a great way to help reduce headaches.

 

Outlook for Headaches During Pregnancy

If you are pregnant, your outlook is good in terms of headaches and migraines. These conditions happen because of the changes the body is going through in a relative short period of time. Always consult with a health professional during pregnancy if you are going to take medications for headaches and migraines because there are certain medications to avoid, especially during the later stages of pregnancy. Also, headaches further on in pregnancy might be indicative of a more serious health issue, like high blood pressure.

 

Generally speaking, consult with a doctor before taking any medications. Also, tell your provider if your headaches change in frequency or intensity. Also, check with your doctor if you are getting headaches that come with blurred vision, weight change, pain in the upper right abdomen, and swelling.

 

IF YOU HAVE HEADACHE, MIGRAINE, OR FACIAL PAIN AND ARE LOOKING FOR ANSWERS ON ANYTHING RELATED TO IT, A HEADACHE SPECIALIST IS HERE TO HELP, FOR FREE!

FIRST, LET’S DECIDE WHERE TO START:

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR THE LATEST INFORMATION, HOT TOPICS, AND TREATMENT TIPS, VISIT OUR FREE BLOG OF HOT TOPICS AND HEADACHE TIPS HERE. THIS IS WHERE I WRITE AND CONDENSE A BROAD VARIETY OF COMMON AND COMPLEX  MIGRAINE AND HEADACHE RELATED TOPICS INTO THE IMPORTANT FACTS AND HIGHLIGHTS YOU NEED TO KNOW, ALONG WITH PROVIDING FIRST HAND CLINICAL EXPERIENCE FROM THE PERSPECTIVE OF A HEADACHE SPECIALIST.

 

IF YOU DON’T HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR POSSIBLE TYPES OF HEADACHES OR FACIAL PAINS BASED ON YOUR SYMPTOMS, USE THE FREE HEADACHE AND FACIAL PAIN SYMPTOM CHECKER TOOL DEVELOPED BY A HEADACHE SPECIALIST NEUROLOGIST HERE!

 

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR FURTHER EDUCATION AND SELF-RESEARCH ON YOUR DIAGNOSIS, VISIT OUR FREE EDUCATION CENTER HERE.

Read More

Last updated on September 17th, 2021 at 06:47 am

WHAT IS TMS (TRANSCRANIAL MAGNETIC STIMULATION), AND CAN IT TREAT MIGRAINES?

@Neuralgroover

TMS, or transcranial magnetic stimulation, is an alternative therapy for pain (including migraine headache) and some mental illnesses. It involves transmitting a magnetic pulse onto the scalp, which induces currents within the brain. This electric field activates neurons in areas of the brain that are underactive; as of now, TMS can reach depths of about 1.5 to 3 cm below the skull surface. There are many different types of TMS, but they all can target specific areas of the brain, depending on where the magnetic pulse is administered. First developed in 1985, TMS was originally, and continues to be, used for clinical trials. It is used to measure motor conduction times and assess neural excitability.

 

What are the types of TMS?

The two main categories of TMS are sTMS and rTMS. sTMS refers to single-pulse TMS. This means that only a single magnetic pulse is transmitted. With rTMS, or repeated-pulse TMS, a train of pulses is administered. Sometimes a pair of single pulses is administered, and this can be referred to as paired-pulse TMS or ppTMS.

 

Another common type of TMS is theta burst stimulation, or TBS. During theta burst stimulation, the magnetic pulse is delivered at a specific frequency that mimics brain waves. This type of TMS is sometimes preferred because it promotes neuroplasticity. It is also often referred to as Express TMS because administration takes only about 3 minutes, whereas typical 10-Hz rTMS methods can take over 30 minutes.

 

Typically, TMS is done in a clinical office and administered by a professional. This is necessary for most types of TMS, including rTMS and theta burst. There are private clinics like TMS & Brain Health that administer TMS in a safe and comfortable environment. However, personal sTMS devices are now available. These mobile neuromodulatory devices can be self-administered at home.

 

What does TMS treat?

TMS has been used in clinical settings to monitor brain activity for over 30 years and is an FDA-cleared treatment for many types of mental illnesses as well as pain management. It is most often used as an alternative therapy for Major Depressive Disorder and bipolar depression that is resistant to standard forms of treatment. Patients with depression who have tried various medications like SSRI’s are often eligible to have TMS therapy covered by health insurance. It is still recommended to resume psychotherapy or other social therapies during and after TMS treatment. TMS can also be effective in treating anxiety, PTSD, OCD, and smoking cessation for some patients.

 

There is also evidence that TMS can effectively treat migraines. sTMS has been shown to be an effective treatment for acute migraines with aura when administered at the onset of aura. It is also an FDA-cleared treatment for migraine without aura, recommended to be administered at the onset of a migraine attack. rTMS also shows promise as a preventative treatment for chronic migraine. Repeated administration of rTMS resulted in a decline in migraine frequency, duration, and intensity.

 

The first device which was FDA cleared for migraine treatment was an sTMS device, discussed further here. It was initially FDA cleared for the acute treatment of episodic migraine with aura in adults in December 2013. It then received FDA clearance for both acute and preventive treatment of migraine in adults in 2017. This clearance was then expanded to the acute and preventive treatment of migraine in children 12 years of age and older in February 2019. Prior models included the Spring TMS and sTMS mini. The newest model, SAVI, is currently the only FDA cleared device for both the acute and preventive treatment of migraine in adults and children 12 years of age or older. Since the device is used acutely and preventively, the FDA approved it for a maximum of 17 pulses per day.

 

The user holds the device against the back of the head, and presses a button to release a very short magnetic pulse at the onset of aura or a migraine attack with or without aura. The magnetic pulse delivers a fluctuating magnetic field which induces a mild electric current through the skull and onto the surface of the occipital cortex (visual cortex) of the back part of the brain. This modifies the electrical excitability and hyperactivity of the cortical neurons to block or prevent the onset of a migraine from evolving to a full-blown migraine. The device stops cortical spreading depression, which is suspected to be the basis of migraine aura in the occipital cortex. It is also suspected to interfere with thalamocortical pain pathways that are normally activated during a migraine.

 

The most common side effects were mild and brief light-headedness/dizziness, tingling over the back of the head where treatment is performed, brief tinnitus (ringing in ears), nausea, and muscle spasm. You should not use this device if you have a cardiac pacemaker, vagus stimulator (VNS) or other implanted neurostimulator, implanted cardioverter defibrillator (ICD) or any implanted medical device that stimulates the body or uses any signal from the body. It is also suggested that patients with implants affected by a magnetic field should not use this device. Examples of such implants include aneurysm clips or coils, cochlear implants, cerebral spinal fluid shunts, bullets or pellets lodged in the head or upper body, metal plates, screws, staples or sutures in skull, neck, shoulders, arms or hands, and facial tattoos with metallic ink. Dental implants, fillings or other dental appliances are okay to use the device.

 

Acute migraine treatment consists of 3 sequential pulses (early) at the onset of a migraine (aura or pain). Then wait 15 minutes. If needed, treat with an additional 3 pulses. Then wait another 15 minutes. If needed, treat with an additional 3 pulses. Studies reported that 39% of patients were pain free at 2 hours.

 

Migraine prevention treatment consists of 4 pulses twice daily. This is performed by giving 2 consecutive pulses, waiting 15 minutes, and then repeating 2 consecutive pulses. Studies reported that 46% of patients had a greater than 50% reduction in monthly headache days and averaged approximately 3 less migraine days per month.

 

The use of non-medication options for migraine such as TMS can help to avoid common side effects of standard abortive pills such as NSAIDs and triptans, and can help to avoid rebound headache (medication overuse headache).

 

What are the side effects of TMS?

TMS is FDA-cleared and it is a very safe treatment option for pain and mental illness. In general, the most commonly reported side effect is light headedness or dizziness directly after treatment that fades quickly. Most patients describe the actual TMS administration to be mildly uncomfortable, and report feeling a tapping sensation on the scalp. Additionally, TMS cannot be administered if you have any kind of metal implants or a high risk of seizure.

 

Occasionally, Virtual Headache Specialist will allow guest bloggers to write or contribute to an article on a migraine related topic. The bulk of this article was written by Ben Spielberg, M.S. with edits and contributions (especially the sTMS migraine treatment discussion) by myself. Ben Spielberg is the Founder and CEO of TMS & Brain Science, a brain health center dedicated to cutting-edge solutions for treatment-resistant depression and many other mental health needs. With his team of passionate mental health specialists, Ben has been a leader in bringing TMS, neurofeedback, and ketamine therapy to Southern California.

 

IF YOU HAVE HEADACHE, MIGRAINE, OR FACIAL PAIN AND ARE LOOKING FOR ANSWERS ON ANYTHING RELATED TO IT, A HEADACHE SPECIALIST IS HERE TO HELP, FOR FREE!

FIRST, LET’S DECIDE WHERE TO START:

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR THE LATEST INFORMATION, HOT TOPICS, AND TREATMENT TIPS, VISIT OUR FREE BLOG OF HOT TOPICS AND HEADACHE TIPS HERE. THIS IS WHERE I WRITE AND CONDENSE A BROAD VARIETY OF COMMON AND COMPLEX  MIGRAINE AND HEADACHE RELATED TOPICS INTO THE IMPORTANT FACTS AND HIGHLIGHTS YOU NEED TO KNOW, ALONG WITH PROVIDING FIRST HAND CLINICAL EXPERIENCE FROM THE PERSPECTIVE OF A HEADACHE SPECIALIST.

 

IF YOU DON’T HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR POSSIBLE TYPES OF HEADACHES OR FACIAL PAINS BASED ON YOUR SYMPTOMS, USE THE FREE HEADACHE AND FACIAL PAIN SYMPTOM CHECKER TOOL DEVELOPED BY A HEADACHE SPECIALIST NEUROLOGIST HERE!

 

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR FURTHER EDUCATION AND SELF-RESEARCH ON YOUR DIAGNOSIS, VISIT OUR FREE EDUCATION CENTER HERE.

Read More