News to Know - March 2013

Seeking Care Is Vital for Migraine Relief

In the United States, some 28 million people experience migraine, and one in four households across the country includes a migraineur. Despite the prevalence of the disorder and its far-reaching effects, fewer than half of migraine sufferers are ever diagnosed—a critical step in getting relief.

In a new small study, researchers Nancy Waltman, PhD, and Catherine Parker of the University of Nebraska Medical Center College of Nursing Lincoln Division and Bryan Medical Center have shown just how important appropriate medical intervention can be in reducing the frequency, severity and disability of migraine.

For their study, they recruited 80 women between the ages of 25 and 67 who were not being treated for migraine and provided them with information on dietary and lifestyle tips to lessen migraine and prescribed medications to prevent migraine attacks.

In studying data from 28 of the participants who kept headache diaries, study leaders found that lifestyle changes alone brought significant improvements in the frequency of migraine attacks—reducing them from an average of two per week to one, decreasing pain levels by 31% and perceptions of disability by 66%.

“The best treatment is a combination of dietary changes, adjustments in sleep and exercise, avoiding triggers and (taking) preventative medications,” Dr. Waltman said.

She noted that while the study was small, its results proved valuable by demonstrating the importance of tailoring migraine interventions to individuals and providing a gauge for conducting a similar study with a large group of participants.

“Our results are promising, and we are recommending a future, larger study,” she said.

This study has not yet been published, and its results should be considered preliminary.

Nerve Stimulation May Show Promise for Migraineurs

A new nerve-stimulating device to treat headache and migraine recently showed promise in the first randomized, controlled study of its kind.

The device, Cefaly ®, works by sending high frequency neurostimulation to the trigeminal nerve, which is frequently involved in head pain.

Researchers led by Jean Schoenen, MD, PhD, a neurologist at Liège University in Belgium, recently enrolled 67 patients in this study, a double-blind, randomized, sham-controlled trial conducted at five Belgian headache clinics. Half the group received treatment for 20 minutes each day for three months, while the remaining half received a sham treatment.

After three months, the group receiving true treatment saw their average number of migraine days each month decrease from an average of 6.9 to 4.9. The number of migraine attacks and the amount of medication that this group took also decreased.

The device, worn above the eyes during treatment, proved to be as safe and effective as some migraine medications, according to the authors, with no reported side effects.

“Clearly there is a need for more therapies,” Dr. Schoenen told MedScape Medical News. “This is just one that might be useful, especially for people who feel uncomfortable taking drugs everyday.”

The authors compared the results of Cefaly in this study to the migraine medication topiramate. The medication, they noted, has a 50% responder rate of 45%, meaning that 45% of patients who take topiramate experience a reduction of 50% or more in their migraine days. For Cefaly, the 50% responder rate was 38%.

Dr. Schoenen also noted that sometimes patients discontinue medications because of their side effects, but he does not expect that would be the case with Cefaly. He did note, however, that some people might find daily treatment difficult in the long term.

Cefaly is available in several countries without a prescription. While it is still awaiting approval in the United States, it is available online, including through Amazon and Costco, and costs between $240 and $365.

Arthur Elkind, MD, the president of the NHF’s board of directors, urged migraineurs to be cautious if they are interested in buying this potential new tool.

“The device when used properly may be effective as a treatment for migraine,” he said. “But before migraine sufferers purchase the instrument from online sources and spend $300 or more, they should await reports from other reliable medical centers that demonstrate Cefaly’s efficacy and safety. They should also wait for regulatory approval in the United States.”

The study appeared online in the Feb. 6 issue of Neurology.

Lightning Increases the Odds for Headache and Migraine

For many years, migraineurs have believed that changes in weather trigger their headaches, yet studies about this subject have been contradictory, with some research seeming to prove them right and other research indicating the opposite.

Recently, however, a father-son team of researchers led a study exploring the link between lightning and migraine. They found that when lightning struck within 25 miles of participants’ homes, for those who already experienced headache or migraine, the likelihood of developing a headache increased 31% and the likelihood of a migraine by 28%. Similarly, new-onset headache and migraine increased by nearly 25%.

One of the lead authors, Vincent Martin, MD, a physician and headache expert at the University of Cincinnati and the vice president of the NHF, noticed that thunderstorms seemed to trigger migraine in some of his patients. With colleagues, including his son, Geoffrey Martin, a fourth-year medical student at the school, he reviewed weather data and the records of 90 patients, 23 from Cincinnati and 67 from St. Louis, who had participated in earlier migraine-related clinical studies. Ninety-one percent of participants were female with a mean age of 43.6 and mean headache and migraine frequencies of 11.7 and 6.6 days per month.

Because lightning frequently accompanies thunderstorms and a variety of weather-related elements, researchers relied on mathematical models to remove the variables, such as barometric pressure, temperature and rain, and found that lightning alone was associated with an increased chance of headache.

“This suggests that lightning has a unique effect on headache that cannot be explained by other meteorological factors,” the authors stated.

The researchers put forth a variety of ideas about which factors might be responsible for these results, ranging from electromagnetic waves emitted from lightning to increased levels of air pollutants and fungal spores.

“Ultimately,” the authors concluded, “the effect of weather on headache is complex, and future studies will be needed to define more precisely the role of lightning and thunderstorms on headache.”

The study appeared in January in the journal Cephalalgia.

Panic Disorder and Migraine: Better Understanding the Connection

Physical and mental health disorders, including depression and anxiety, often afflict migraineurs, with current research indicating that panic disorder (PD) is the anxiety disorder most often associated with migraine.

In a review article in the January issue of the journal Headache, Todd Smitherman, PhD, FAHS, from the University of Mississippi, and colleagues explored PD, migraine and the connection between the two to better understand assessment and treatment of affected patients.

In the general population, anxiety disorders are the most common psychiatric disorder, appearing at some point in nearly 30% of the population. Among migraineurs, the odds increase, with up to 58% of the population experiencing at least one anxiety disorder during their lifetime and between 5 and 17% experiencing PD, which is marked by short periods of intense fearfulness, or panic attacks. Rates of PD are even higher for those with chronic migraine (25 to 30%) and migraine with aura. The authors note that PD is also most common among migraineurs who seek treatment and those who seek care from specialty clinics.

This connection is also evident when examining the link from the other direction. More than 60% of outpatients with PD experience migraine, the authors noted.

While the two disorders may seem quite different initially, they share many characteristics: They are both chronic disorders that manifest themselves episodically. During an attack, those affected are functionally impaired, and between episodes, there is considerable worry about when the next attack might appear. Additionally, both disorders may include similar symptoms, including gastrointestinal distress, dizziness and fear.

When a person experiences both PD and migraine, their medical costs rise significantly compared to migraineurs without a psychiatric disorder; those with both disorders report more disability and functional impairment and decreased quality of life. They are also at an increased risk of overusing medications and developing medication overuse headache.

In the clinic, the implications of the PD-migraine link illustrate that it is important for health care professionals to assess their migraine patients for panic and to rule out other medical conditions. When medications are warranted, the authors note that the disorders are currently best treated with separate pharmaceuticals. When PD is moderate to severe, patients should be referred to a mental health professional to provide panic control treatment and pharmaceutical treatment, if appropriate.

Finally, the authors call for more research so that the underlying mechanisms of both disorders are better understood and that cost-effective and integrated treatment may be developed.

Reader’s Mail

Unusual Headache Presentation Calls for Expert Help

Q: I develop a severe headache at the back of my head behind my ears when I laugh too much. My skull gets tightened and pressurized so much that it feels that if the pressure doesn’t stop, my head will explode. It also happens when I get nervous. Is this normal, and what kind of headache is this?

A: The description of your symptoms may be due to several causes. Above all, it must be determined if there is something anatomically wrong inside your head. An MRI scan is needed to determine that there is no abnormality, especially in the area known as the posterior fossa. Another condition to be excluded includes a Chiari malformation. It may also be necessary to do an MRA (magnetic resonance angiogram) and MRV (magnetic resonance venogram) to observe the vascular structures inside your head.

Once an abnormality has been ruled out, the differential diagnosis would include primary headaches; perhaps the strain of laughing would place it in the category of "primary exertional headache."

I recommend that you see a headache specialist to explain this unusual headache pattern.

Edmund Messina MD, FAHS
Medical Director
Michigan Headache Clinic
East Lansing, Michigan

The Libby Fund Receives Support

On March 10, 2013, Anne and Elon Spar welcomed more than 70 guests to their home in Armonk, New York, for a fundraiser for The Libby Fund, which supports research on hemiplegic migraine.

Emily and Paul Kandel, honorary board members of the NHF, greeted the guests; at the gathering, NHF board member Mark Green, MD, discussed the importance of the research The Libby Fund supports. Dan Levy, PhD, of Harvard Medical School and a recipient of a Libby Fund grant, discussed the ongoing research and how it will impact the understanding of hemiplegic migraine.

The final speaker was Eric Kandel, MD, who spoke of his work in migraine early in his career while he was at the National Institutes of Health. Dr. Kandel won the Nobel Prize in 2000 in Physiology or Medicine for his research on the physiological basis of memory storage in neurons.

The attendees included Arthur Elkind, MD, the president of the NHF; Leah Green, MD; Shannon Babineau, MD, and Kate Mullin, MD, both of Mount Sinai Medical Center in New York City. More than $6,000 was raised at the event.

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