Questions from the clinic: ‘I’ve heard about injections for chronic migraine, and I’d like to ask you some questions about it’

Please note as per TGA guidelines we are not permitted to mention the name of the product discussed in this blog entry

Part 2

Q How soon might I see a benefit?

A Patients may take 4 weeks after the injections to notice benefit, although they may see improvement sooner. In some patients a benefit may not be seen until after their second injection series.

Q May I take other medications for headache while I’m receiving injection therapy?

A Yes. Prompt treatment of acute migraine headaches with appropriate medications and in a frequency that will not cause medication overuse headaches is advised. Your migraine specialist will provide you with an acute migraine treatment strategy. This will assist the injection therapy to achieve a remission of your chronic migraine back to the episodic form of that headache disorder.

Q I am thinking about trying for a pregnancy in the next few months, can I still commence injection therapy?

A No, injection therapy has not been tested in pregnancy and therefore should not be administered to pregnant woman or in women who may become pregnant in the 3 months after it is injected. It should also not be used when patients are breastfeeding.

Q What happens after the first set of injections?

A Afterwards patients are able to drive home and resume normal activities. Vigorous neck exercises, neck massage, and or physiotherapy are however discouraged for 24 hours after the procedure.

There is good evidence that when it works, injection therapy has a cumultative effect, with better and better response with each cycle administered every 3 months across a year.
However after 2 injection cycles, as per PBS criteria, if no improvement is noticed, the injections should be discontinued.

Q: My injection therapy for chronic migraines has been working well, but I’m worried that it will stop being effective, what are the chances of this happening?

A A study that sought to answer this question was recently published by Cernuda-Morolion et al in Cephalagia 2015, Vol 35 (10):864-868 titled ‘Long-term experience with (injection therapy) in the treatment of chronic migraine: What happens after one year?

• Only in around 1/10 patients did injection therapy lose their clinical efficacy after more than one year of treatment
• There was no failure after the third year of treatment
• In 43% of cases, injections can be delayed to every 4 months (16 weeks) after the first year of treatment

Note: Information on this site is not a substitute for professional medical advice

References:

Headache: The Journal of Head and Face Pain, 2014, American Headache Society, Tepper MD

Questions from the clinic: ‘I’ve heard about injection therapy for migraines, and I’d like to ask you some questions about it’

Please note as per TGA guidelines we are not permitted to mention the name of the product discussed in this blog entry

Part 1

Q  Should I consider injection therapy for my frequent migraines?

A  Yes, if you are over 18 years of age, not pregnant, breastfeeding or planning for a pregnancy in the next 3 months, and suffer from chronic migraine. You should also consider the therapy if at least 3 preventative medications provided from your doctor have resulted in limiting side effects or have been unable to provide you with significant benefit.
Chronic migraine is a disabling problem for 2% of the population, having an adverse impact upon an individuals quality of life, as well as their families. Injection therapy is the first approved intervention found to result in a significant improvement in this disorder.

Q How does a migraine specialist know that I am suffering from chronic migraine?

A  A migraine specialist will be assessing you for the diagnosis of migraine, and then for the frequency of headache and migraine events to determine if a diagnosis of chronic migraine can be made. A migraine headache is diagnosed when characteristic features are associated with your headaches, that being light and noise sensitivity, nausea, as well as pain that is moderate to severe in intensity.

Q What is the active ingredient in injection therapy?

A  The active ingredient is an injectable protein produced by a bacterium (Clostridium botulinum) that paralyzes muscles into which is in injected.

Q  Are the injections the same for every patient?

A  Yes, and the precise location and quantity of each injection has been tested extensively for safety and effectiveness in a wide variety of disorders.

Q What are the possible side effects?

A  Injection therapy is generally well tolerated. A brief, stinging sensation can be produced at each injection site. In a small percentage of patients, (3-9%), neck pain, headaches, heaviness of the brow and or eyelids can be experienced, however these are all temporary should they occur.

Q How does injection therapy work for migraines?

A  Injection therapy is believed to work for migraine by blocking pain signaling transmission between the head and neck and the central brain where migraine is generated.

Q Will injection therapy cure my migraines?

A  No, injection therapy is not a cure for migraines, it does however represent an effective preventative intervention in many migraine patients. When it works for chronic migraine, the results can be dramatic, not just in reducing headache days but with significant improvement in headache related quality of life assessments

Note: Information on this site is not substitute for professional medical advice.

References:

Headache: The Journal of Head and Face Pain, 2014, American Headache Society, Tepper MD

As with a variety of health issues, chronic migraine is best treated by preventing its occurrence in the first place. Once chronic migraine has developed, its successful treatment, with remission back to the episodic form, will require the expertise of a migraine specialist to achieve.

What are the risk factors for chronic migraine development?

• Increase in headache attack frequency
• Overuse of acute headache medications
• Obesity
• Disorders of mood (anxiety or depression)
• Insomnia, disrupted sleep

 What can you do to prevent chronic migraine?

• Patients with episodic migraine need to avoid completely the use of strong opioids such as Endone, Oxycontin, and or Pethidine.
• Many patients are also not aware that common over the counter medications such as Nurofen Plus, Panadeine, and Mersyndol, contain codeine, which is a weak, but potentially addictive opioid.
• If your headache frequency is increasing, seek review with a migraine specialist, do not wait until your headaches occur daily before you get help
• Treat headaches early and aggressively, your migraine specialist will be able to provide you with a plan for acute headache treatment
• The addition of a medication to prevent migraines may be required, and your migraine specialist can advise you of your available options.
• Begin and stick with a regular exercise plan
• If you are overweight/obese, commence a weight loss program
• Seek treatment for any co-existing disorder of mood or sleep

Information: Information on this site is not a substitute for professional medical advice.

 References: Migraine ‘Chronification’: What you can do, Headache 2009, American Headache Society, Rothrock MD
Over the counter sale of codeine pain killers such as Nurofen Plus and Panadeine may end, April 2015, Sydney Morning Herald, Aisha Dow, Julia Medew

Questions from the clinic: When should I take my acute migraine medication?

Answer: As early as possible!

At our migraine clinic we have noticed a common issue amongst our patients- they don’t treat their migraines early! Instead they delay treating a headache because they ‘wait to see if it’s going to be a migraine’

At our migraine clinic we advise our patients that the key to effective management of an acute migraine attack is early recognition and treatment

Migraine patients often report that they suffer migraines and headaches, though most headaches experienced by a patient with migraine are in fact migraine headaches, and will respond to their usual acute migraine medication.

As a migraine evolves its responsiveness to treatment decreases. Medications developed specifically for acute migraine treatment, are far more effective if taken when the headache is still early, and mild to moderate in intensity, rather than later, when moderate to severe in intensity.

Delaying taking acute migraine medication risks not resolving the headache completely, and this can be linked to the early recurrence of further severe headaches!

Note : Information on this site is not a substitute for professional medical advice.

References: Acute migraine treating early, Headache 2009, American Headache Society, Rothrock MD

Around 30-50% of migraine patients will sometimes experience dizziness, a sense of spinning, or feeling off balance with their headaches. Migraine specialists now call this vestibular migraine.

A frequent additional symptom is head motion intolerance, ie imbalance, and a sense of motion, often with nausea, aggravated or triggered by head movements.

Vertigo provoked by moving scenes such as traffic or movies, ie visually induced vertigo, can be another prominent feature of vestibular migraine.

Vertigo can precede headache, may begin with headache or may appear late in the headache phase. Many patients experience attacks both with and without headache. In some patients vertigo and headache never occur together, and this can make the diagnosis of vestibular migraine at times challenging.

Along with the vertigo, patients may experience light and noise sensitivity and or visual or other auras, and this can help the migraine specialist establish the link to migraines. Triggers for vestibular migraine attacks can also be similar to those seen in more typical migraine, for example, menstruation, lack of sleep, stress, specific foods, bright lights, strong smells or noise.

There are warning signs or red flags that vertigo is not part of a migraine, including new and sudden onset, sudden hearing loss, ear fullness, loss of balance alone, +/-weakness, and these suggest urgent evaluation for a non migraine disorder.

Otherwise, if a diagnosis of vestibular migraine has been established by a migraine specialist, standard migraine prevention and attack treatment strategies are typically prescribed, and these are frequently effective.

 Note:Information on this site is not a substitute for professional medical advice.

References:

Vestibular Migraine, Lempert MD et al, Seminars in Neurology 2013;33:212-218

Migraine associated Vertigo, Tepper MD, Headache 2015, American Headache Society

In the Migraine Specialist clinic we are often asked the following question: Does drinking coffee cause or cure my headaches?

The answer is not completely straightforward and there are a couple of things you need to know about the relationship between coffee and headaches because caffeine is a two-edged sword when it comes to headaches. It can lead to either generation or alleviation of headaches.

Caffeine has different effects with episodic intake versus regular exposure.

Regular use of caffeine leads to physical dependence, and abstinence can result in a withdrawal syndrome. This syndrome includes symptoms suggestive of migraine including severe headache, fatigue, nausea and vomiting.

The higher prevalence of migraine reported on weekend mornings has been partially attributed to the withdrawal effects of caffeine.

Regular caffeine consumption is associated with chronic migraine, the development of chronic daily headaches and analgesic overuse headaches. To reduce the risk of developing these conditions, patients prone to headaches should limit their caffeine exposures.

On the flip side of the equation, however, episodic caffeine intake, although in some individuals is capable of triggering a migraine, may prove to be an effective adjunct in treating acute migraine. Certainly, some of our patients are very surprised when we recommend their acute oral migraine medication be taken with a strong coffee!

During migraine attacks stomach emptying may be delayed, and oral medications are unable to be absorbed and exert their treatment effect. Caffeine can improve the stomach’s motility, and, as well as allowing for absorption of oral medications, may exert a direct pain-relieving effect itself.

Note: Information on this site is not a substitute for professional medical advice.

References:

Caffeine and headaches, Shapiro, Neurol Sci (2007) 28:S179-S183

 The Truth About Triggers, Rothrock, Headache 2008 American Headache Society

“Does being overweight have anything to do with my chronic headaches?”

Normal weight people with migraine have around a 3% chance of developing chronic headaches in a year. If they are overweight, they have 3 times that chance. With obesity, the chance of chronic migraine increases 5 times.

Obesity has not been found to cause migraines, only to increase their frequency. Both conditions however are associated with the release of pain generating hormones, and perhaps there is an additive effect. Migraine has also been associated with an increased risk of heart attack and stroke, and this may relate to higher levels of insulin, glucose and cholesterol in migraine patients.

Keeping track of your weight is therefore important, and there are a few issues to consider:

• Several oral medications prescribed to treat migraine can be associated with weight gain, and its important to be aware of this. Certainly this is one of the benefits of injection therapy for migraine, as weight gain and or changes in appetite are not associated with this treatment.
•  Keep active, and in fact regular aerobic exercise has been shown to result in fewer headaches.
•  Make sure your doctor monitors your cardiovascular risks, controlling blood pressure, cholesterol, blood glucose and not smoking, are all important to lessen your risk of a heart attack or a stroke.

If you are overweight, addressing this issue, as part of your entire migraine treatment strategy can result in better health overall, with the added benefit of less headaches!

Note: Information on this site is not a substitute for professional medical advice.

References: Headache: 2013 American Headache Society, Tepper MD

One question we are regularly asked at Migraine Specialist is whether perimenopause or menopause are connected and if menopause has an impact on the frequency and severity of headaches and migraines. We know that women are more likely to suffer from migraines and we know a lot of women in this demographic visit us at Migraine Specialist, so we wanted to share more information on this topic with our wider community.

“Does Perimenopause or Menopause have anything to do with my frequent headaches and migraines?” 

A number of our patients are women between the ages of 40-50 years old and many of them experience perimenopausal type symptoms including hot flushes, insomnia, night sweats, decreased libido and irritability. Many also experience an increased headache frequency during this time, so it’s no wonder they ask “is menopause and migraines connected?”

A study recently was undertaken to examine the relationship between headache frequency and menopausal transition in women with migraine. The study provided good evidence that high frequency headache is indeed increased during the perimenopausal period.

The identification of this increased risk during the menopausal transition is important, in that it suggests a need for effective migraine preventative treatment during this time of a woman’s life when they are also experiencing hormonal changes a during this stage of life. That’s where our team of specialists can help – if you are a woman who is suffering from regular headaches or migraines and at this stage of your life, get in touch with our team and we can provide some more information and steps to support your treatment.

Note: Information on this site is not a substitute for professional medical advice.

References:

Menopause are associated with High Frequency Headache in Women with Migraine Prevalence and Prevention Study , Martin et al, Headache 2016; 56:292-305

‘Does my poor sleep have anything to do with my headaches and migraines?’

Insomnia, ie difficulty with falling asleep, or staying asleep as long as desired, is the most common sleep complaint among patients with chronic migraines.

Clues to a sleep disorder include:

• snoring
• gasping during the night
• falling asleep during the day
• not feeling rested upon awakening
• the desire to move one’s legs when trying to sleep (frequently associated with restless legs syndrome, & this can further disrupt sleep)

If symptoms suggestive for possible obstructive sleep apnoea, RLS, or another sleep disorder are present, then formal sleep testing may be required.

Even if formal sleep testing is not required, consistent behavioural changes are needed for those with chronic headaches and sleep problems.

Behavioural changes are safe, can enhance functioning during the day, and many find, that if they can improve the quality of their sleep, their headaches do improve.

If behavioural changes are insufficient however, medications may be required.

What are the behavioural changes I should consider?

Engaging in restful and non stress producing activities before going to sleep is important. In addition regular sleep habits of going to bed within an hour of the same time every night, and getting up at similar times is advised.

Sleeping in on the weekends to catch up on a sleep deficit during the week can also be problematic, as it can trigger, ‘let down migraines’

Other issues to be mindful of is that frequent intake of caffeine can lead to a worsening of a sleep disorder, with a caffeine withdrawal headache experienced during the night. Individuals with medication overuse headaches can also experience their medications wearing off during the night, triggering a headache.

It has also been reported that nocturnal awakening headache was 14 times more prevalent in women during the perimenopause period, and headaches associated with this stage in a women’s life will be discussed in a follow up blog.

Note: Information on this site is not a substitute for professional medical advice.

References:

Headache: The Journal of Head and Face Pain. Deborah Tepper MD, 2015 American Headache Society

 Does menopause influence nocturnal awakening with headache? Lucchesi LM, et al, Climacteric 2013

During our migraine clinics we get asked many questions by patients, who are seeking an improved understanding of their chronic migraine condition. We believe that better education of patients leads to improved outcomes. We have therefore decided to publish, in a series, our responses to their most frequent queries.

‘What do you think of Physical Treatments (Physiotherapy, Chiropractic, Osteopathic, Massage therapy) for my Migraines?’

A topic that we are frequently asked to comment on is the use of physical treatments for migraine headaches.

As migraine is commonly accompanied by neck pain or other symptoms, physiotherapy and other physical treatments are often provided.

In 2005, a literature review was undertaken of clinical studies, systemic reviews, and case series, that assessed the treatment of headache or migraine with chiropractic, osteopathic, physiotherapy or massage interventions. It was titled ‘Physical Treatments for Headaches: A Structured Review’

The authors noted that evidence is lacking regarding the efficacy of these treatments in reducing headache frequency, intensity, duration and disability, and that further studies of improved quality were needed.

Conclusions

In the absence of clear evidence about their place in treatment, the authors felt that the use of physical treatments should complement, and not replace, better validated forms of therapy.

Validated forms of therapies have been subject to randomized controlled trials and have shown a significant reduction in the number of headache and migraine free days, as well as migraine severity.

With the exception of high velocity chiropractic manipulation of the neck, physical therapy treatments are unlikely to be dangerous, although they are often expensive, and may result in lost treatment opportunities by providing treatment which is lacking in clear evidence and is potentially ineffective.

Note: information on this site is not a substitute for professional medical advice

References:

Physical Treatments for Headaches: A Structured Review’ David M Biondi, Headache 2005;45:738-746