It’s good to see researchers paying more attention to neck pain as a symptom of migraine. One example is a study being published this year in the journal Toxins.
In this case, the study focused on onabotulinumtoxinA treatment, commonly known under the brand name of Botox. Botox has become a well-known treatment for chronic migraine, although we still have a lot to learn about the best way to use it.
This study focused not only on headache pain, but also neck disability and pain. Researchers used the Neck Disability Index (NDI), a ten-question survey filled out by patients to measure just how much neck pain is affecting their lives (see this example). For example, do you have trouble driving because of the pain? Are you avoiding recreational activities? Is neck pain robbing you of sleep?
A single onabotulinumtoxinA session did significantly decrease neck pain and disability in the patients over the next three months. Significant disability due to neck pain became mild, and headache pain decreased as well.
The authors of the study noted that this could mean a significantly better quality of life. These were patients who, at the beginning, were significantly disabled by both headache and neck pain.
This was a short-term study, so the researchers would like to see if these improvements hold over a longer period of time, with further treatments.
Still, there are a couple of things that can be taken from this study. First, be aware of neck pain and stiffness, during and in-between your migraine attacks. This is a symptom which may be causing you a lot more trouble than you realize. Second, if you have chronic migraine and have considered Botox as a treatment, this might be a further reason to give it a try. Be sure to keep track of both your headache and migraine symptoms and your neck pain, and share your results with your doctor.
By now, Botox has become a common treatment for migraine. But AEON Biopharma wants to create a similar but better treatment.
Botox is a brand name for injections made from botulinum toxin A, specifically onabotulinumtoxinA. Given by injection, it has been helpful as a migraine preventative.
In spite of calls for standardization, the fact is that we still have a lot to learn about how to best use botulinum for migraine. How many injections is best? Where should the injections be? How often? Is there a difference for different types of migraine?
Another type of botulinum toxin A is prabotulinumtoxinA (PRA). Like onabotulinumtoxinA (ONA), PRA is used to fight wrinkles. Different types of botulinum come from different sources and processing.
AEON wants to use their own special version of PRA to help prevent migraine. And they’re hoping that they can do it with fewer injections than the typical Botox treatment.
This new treatment is currently known as ABP-450. ABP-450 is entering into phase 2 trials in Australia, Canada, and the USA, so you can check out more information here if you’re interested in being involved. Both episodic and chronic migraine patients are invited.
ABP-450 is also being studied as a treatment for cervical dystonia, a painful condition involving neck spasms.
A recent review of migraine studies may have uncovered a hole in the research. Are people with chronic migraine and daily headache being overlooked?
Admittedly, it may be hard to exactly tell what’s going on when a patient simply has constant headache pain. Once you have chronic migraine, that’s an attack at least every other day. Who is to say that the headaches “in between” aren’t just migraine attacks “coming or going”?
But researchers for the Revista de Neurología (Neurology Magazine), a journal in Spain, discovered what may actually be a big problem with the research.
When a clinical trial starts for migraine, researchers are looking to be as precise and clear-cut as possible. They want people with migraine, or without it. And they want to know if it’s episodic or chronic. They don’t want people in mysterious in-between land. Which means that you’re not likely to even get into the study if you have migraine as well as some unspecified daily headache.
The researchers from Revista de Neurología 1.7 – 3.3% of migraine patients may fall into this category (in case you’re wondering, that’s a lot of people!). So, although current studies may benefit them, essentially these people are hardly being studied at all.
OK, maybe they simply have a slightly different manifestation of chronic migraine. But what if there are actual biological differences in these patients? That could mean that treatment that work might be quite different for them.
As the researchers write in their abstract:
They may have a longer lasting migraine and different response to treatment. Patients with chronic migraine and daily headache may have complex pathophysiological mechanisms that favor the daily manifestation of migraine
The only bit of treatment wisdom that they pulled out for the abstract was that OnabotulinumtoxinA (Botox) may be useful for these patients. But they admit simply that “management of these patients is a therapeutic challenge”. Indeed!
We need to find a way to better help these patients, and part of that is actually taking the time to study which treatments work best for them, even if they represent a smaller percentage of migraine patients.
Do you suffer from chronic migraine as well as daily headaches? Have you been shut out of a trial or treatment or service because of it? What treatments have you found helpful?
Botox has become so connected to migraine treatment over the last few years, that we may be forgetting its possible value for other headaches.
Two patients with cancer were recently treated at the MD Anderson Cancer Center. Both had brain tumours, though of different types.
After Botox injections both patients experienced fewer headache days, shorter headaches, and less intense headaches. There were no complications, and quality of life improved.
Dr. Alexander Mauskop of the New York Headache Center comments:
It is not surprising that Botox could help headaches caused by a brain tumor. The brain itself is not pain-sensitive – neurosurgeons can cut it in an awake patient without causing any pain. Most of the pain originates in the brain covering called meninges which are innervated by the trigeminal nerve and which can be stretched and irritated by a tumor. The trigeminal nerve also provides sensation over the face and the anterior part of the head. Botox works by reducing pain signals sent from the trigeminal nerve endings to the brain.
The end of the story is that doctors can explore the use of Botox (onabotulinum toxin A) for headache and migraine symptoms that may have a variety of causes. The authors of this study conclude: “With careful dose and injection site adjustment based on tumor location, use of Onabotulinum toxin A injections is a safe practice in patients with diagnosis of brain tumor headaches.”
Migraine with aura actually refers to a whole set of clinically different types of migraine. It’s characterized by temporary symptoms such as seeing flashing lights or patterns (visual aura), or a feeling of “pins and needles”, numbness, or problems with speech. (Read more here – Migraine with aura)
So obviously experiencing or not experiencing aura means that the symptoms are somewhat different. But is migraine with aura actually a different disease? Should it be treated differently? Is it doing something different to your body than migraine without aura?
These are questions that doctors and researchers have been struggling with for many years. A new report in The Journal of Headache and Pain is helping to direct the discussion toward future research.
There is a lot of discussion about whether or not we should call migraine a “disease”, but researchers use the word “etiology”. That means, does migraine with aura have a different basis, a different cause. We don’t know what causes migraine, but we have clues.
There are hints that migraine with aura may have a different etiology, but we don’t know for sure. As we’ll see below, it does sometimes respond differently to treatment, and it can affect the body in different ways. Is it just a variation of migraine? Or is it really different?
And this is complicated by the fact that many people experience both migraine with and without aura.
Should treatment be different for Migraine with Aura?
Generally speaking, there has not been a different treatment regimen for migraine with aura. And with good reason – most studies show similar results for both. However, there are some exceptions.
For example, magnesium may work better for those who have aura. Botox may be another example.
A rather interesting example was tonabersat. Don’t feel bad if you haven’t heard of it. It’s a “gap-junction modulator” that actually inhibits the cortical spreading depression in the brain which happens during a migraine attack – and which seems to directly influence aura. In trials, tonabersat at first didn’t seem very effective – until patients with migraine with aura were separated out. Then it was shown that it seems to help only patients with aura.
So if we target the cortical spreading depression (CSD), would that stop the attack in patients with this type of migraine? Well, the jury is still out. We often talk about migraine as a “chain reaction” here, but we’re still not sure if the CSD is just a link in the chain, or if it’s more part of a “web” of biological changes.
However, the study of tonabersat may give us new insights into how migraine should be treated.
Does Migraine with Aura affect the Body differently?
Yes, it seems to. Although other types of migraine may raise your risk of cardiovascular problems (think heart attack, stroke, etc), migraine with aura does seem to uniquely increase your risk of ischemic stroke in particular. There may also be differences in blood flow and the effect on the brain itself.
In many trials, migraine with aura was also more difficult to treat – it simply didn’t respond as well to typical treatments.
Interestingly, one study showed that women with migraine with aura are more likely to suffer from anxiety and depression, compared to those with other types of migraine.
Conclusion
Researchers want to see more studies on targeting migraine aura itself. They also feel that it would be worth it to differentiate more between the two major types of migraine in studies, so that more information can be gathered.
At this point, very little is understood about the difference between types of migraine, other than the differing symptoms. However, it is clear that there are differences beyond symptoms – migraine with aura may be harder to treat, may respond better (or worse) to individual treatments, and does seem to change the brain and body in some different ways.
