James

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Posts by James Cottrill:

22 April 2024

Occipital Nerve Stimulation for Cluster – Why does it “sometimes” work?

When we first discussed occipital nerve stimulation back in 2007, the results were promising, but not consistent. Now that’s not unusual for an early study. But when it comes to conditions like cluster headache, there’s another problem.

Occipital Nerve Stimulation results are varied!

Cluster headache is certainly a rarer type of headache disorder. So when you have fewer people experiencing it, you’ll also have fewer trying a specific treatment, and fewer people in clinical trials. So it takes a long time to get results – and those results may be less reliable than they would be with a larger group.

Occipital nerve stimulation remains a promising treatment today, and also a treatment that doesn’t work consistently. That fact was brought to the attention of researchers in the Netherlands, who published a study last year entitled “The Untold Story of Occipital Nerve Stimulation in Patients With Cluster Headache: Surgical Technique in Relation to Clinical Efficacy”. In their report, they included the above statistic for “efficacy” (usefulness – success) of the treatment – 35.7% to 90%! Quite a variation.

Occipital nerve stimulation involves implanting a small device surgically. The device provides “neurostimulation” for the occipital nerves. As this report points out, “the physician aims to target all the occipital nerve branches simultaneously”. The stimulation seems to interrupt pain signals, providing pain relief.

So why doesn’t it consistently “work as advertised”? The researchers found two variables. The first one is – you! The exact makeup of your body is not the same as someone else’s. You can’t just cut someone open and find the exact same nerves in the exact same place.

Now, of course, your surgeon is aware of this. But there’s only so much that a doctor can do.

One thing they can do it standardize surgical techniques. If all doctors, for example, measured in the same way when they implanted the device, we would at least have a more similar treatment.

But that’s not what’s happening. Doctors may use significantly different methods, and also record different information. That means that we can’t even properly compare clinical trials, because we can’t compare exactly what the doctor did.

These researchers are recommending certain points of standardization so that we can properly compare results. This may mean that doctors try to find the best technique based on the current research, and go with that. But it also may mean different techniques that are measured and reported in a standardized way, so that results can be better compared.

When looking for a surgeon, it would be helpful to know what the success rate of this treatment is for their patients. But it also would be nice to know what standards they are following.

This is not just a concern in cluster headache surgery, but in many types of treatment. Though we wouldn’t want to restrict doctors from the treatment they feel is best for you, we also want to make the most of each treatment, so that everyone can improve.

13 April 2024

Does Migraine Make You Sleep More – or Less?

James Discoveries & Stats 0

A recent study and review of previous studies came to an interesting conclusion. Maybe migraine headache pain isn’t causing as many sleep problems as we think. But that doesn’t mean migraine and sleep aren’t related.

The study, published earlier this year in the journal Brain Communications, reported on a study with mice to see just how much migraine pain interfered with sleep. And the surprising result was: not much.

Let’s put it this way. Looking at this research and other studies, migraine does seem to affect sleep in certain ways (for example, migraine may affect REM sleep). But we can be forgiven if our perception is an exaggerated connection – when you’re writhing in pain, you’re desperate to sleep – and sometimes sleep just won’t come.

However, for some patients, they do sleep more with migraine. This may be a physical result of migraine itself, or simply because they’re trying to sleep more, and looking for a dark, quiet room.

I would be interested in your comments below, to hear if you have found that migraine pain actually results in less sleep or more sleep overall.

But that’s not the end of the story. The researchers confirmed again that migraine is associated with sleep disorders, and that sleep problems may trigger migraine attacks. In fact, sleep disorders may play a part in migraine becoming chronic. The connection between sleep and migraine is real, but complex. As a simple example, a poor night of sleep may not mean a migraine attack the next day, but it may increase your risk the day after that.

Sleep schedule, along with diet, may be one of the most powerful indicators of future migraine attacks. Though we all get frustrated when we can’t “sleep away” a migraine attack, we should also pay attention to daily sleep patterns in order to prevent future attacks.

5 April 2024

CGRP Medications: Better for Men, or Women?

James Discoveries & Stats, Information, Medications 0

CGRP related medications for migraine are helping a lot of people. But if you’re going to try one, which medication should you start with? Does your sex make a difference?

Gepant drugs - a difference between women and men?

This is a question that is rarely asked or studied. That’s why a study review published in the medical journal Cephalalgia this year caught my attention. It was one of many studies on CGRP-related drugs – but in this case it was looking at the difference between men and women.

And in the case of one type of drugs, there was a difference – the “gepants” – that is, CGRP receptor inhibitors/antagonists. The specific drugs we’re talking about are:

ubrogepant (Ubrelvy)
rimegepant (Nurtec ODT)
zavegepant (Zavzpret)

Now, when these medications are used for acute migraine treatment – that is, when they’re taken to stop a migraine attack in progress – the evidence is positive. For women. However, for men, there is not yet enough evidence to show a clear benefit.

That doesn’t mean they won’t work for you – and maybe future studies will show a clearer benefit. But it could be that some of the CGRP medications simply work better in women.

It would be helpful to have further studies here, because if this difference stands up in further trials, it would be an easy way to pop certain types of medication higher on the list, because they’ll have a better chance of success, for you.

What about other CGRP medications? The meds for chronic migraine known as CGRP antibodies (the ones that end in “umab” – like fremanezumab or erenumab) seemed to work well for both sexes. Preventative CGRP medications also seemed to help both men and women, but the authors of the study would like to keep an eye out for differences in future studies.

Again, at this point this information shouldn’t stop you from trying CGRP medications. It may be information that can be added to the other info your doctor has in order to decide which to try first.

That being said, we look forward to future studies. Anytime we can make the path shorter to something that works to fight your migraine, we’re very interested.

It will also be very helpful in the future to find out why this is, so that we can better target migraine attacks.

To check out the study for yourself, click on Evaluation of outcomes of calcitonin gene-related peptide (CGRP)-targeting therapies for acute and preventive migraine treatment based on patient sex (pdf).

28 March 2024

Let’s talk about “Brain Organoids”.

James Discoveries & Stats, Information 0

Migraine research, and research on the brain and nervous system, has come a long way in the past 30 years. But researchers are only partially aware of how far we have to go.

*Intestinal organoid*
*(photo courtesy Meritxell Huch)*

Why? Because the human brain is incredibly complex. Few people realize just how little we know about how it works – and, in fact, how the human body as a whole works.

Here’s one of the big challenges when it comes to migraine research. When you’re investigating a new medication, traditionally you’ll have animal trials. Normally you will have safeguards for the animals too, but you do this so that the higher risk goes to the animal and not to the human.

But ethical questions aside, the fact is that the brain of a rodent is incredibly different from the brain of a human being (which is perhaps why Pinky and the Brain haven’t taken over the world). And so medications that may show some promise in the animal turn out to be useless in the human. A waste of time and money.

Brains of deceased humans have also been studied for migraine research – but as you may guess, there are severe limitations to that as well.

So, what if we could test a human brain – or at least some “living” human brain tissue – or any part of the body, for that matter, without actually hurting a human? Enter organoids.

Organoids are tiny 3D bits of human organs grown in the lab. And you have already guessed what brain organoids are. Another step is to take different organoids and put them in a system, so that you can test human-like organ systems. This is done using – no kidding – “assembloids”. But as you can imagine, this is way beyond putting together an Ikea shelf.

These systems can be put together to model certain diseases, such as Parkinson’s or Alzheimer’s. We can learn more about how these diseases work, and even test out treatments.

This is a very promising field of study, but there are two big hurdles. First, the challenges/limitations of the process as it exists today. Second, ethical/wider dangers concerns.

This amazing technology is not without its limitations. For example, scientific study requires a limitation and understanding of variables. Today, there is a variety of methods in the organoid world, and even if you standardize the methods, it’s very hard to get things exactly the same every time. Scientists need to find methods that will limit the variables.

Also, it’s a challenge to create a system complex enough to truly help us understand the migraine chain reaction. We will always be getting a partial view of what’s going on in the human body.

There are a host of ethical concerns as well, including concerns about the dangers of some types of organoid research in particular. For example:

Does the original tissue come from an ethical source? Was anyone harmed in the process?
What are the limitations to combining human and non-human tissue? Both animal rights and human rights activists will have problems here. This is called chimera research – when tissue/DNA from more than one species are combined. And we’re especially talking about human tissue. This type of experimentation could have series consequences for the futures of more than one species if it goes the wrong way.
How complex are these systems going to be? What if we can create a self-aware human being, for example?
What about genetic manipulation? What if those genetic changes affect the human species in general?

And remember, although we’re very thankful for ethical migraine research, there are many doing experimentation around the world for reasons which may include the intent to harm, not to help.

Most of these hurdles can probably be overcome in theory. Excuse the cliché, but I think we all hope that this powerful tool will be used for good and not evil. It has great potential when it comes to migraine research, so we look forward to seeing what is to come in the years ahead.

23 March 2024

Migraine Surgery: Why does it fail?

James Discoveries & Stats 0

A recent review at Cureus Journal of Medical Science took a look at the success and failure of a certain type of surgery for migraine. One of the key questions was – why does migraine surgery fail?

At first, the statistics in the report look pretty good. Up to 80% of patients experienced “complete elimination of headaches”. Naturally, we should be suspicious of that “up to”. But also, remember that this is going to be a very specific group of migraine sufferers, those who were already likely to benefit from this type of surgery.

This type of surgery for chronic migraine sufferers focuses on trigger points, which may be different for each patient. The surgery works by relieving irritation to certain nerves, or by blocking pain signals from certain locations.

These are patients who have also tried other treatments, because surgery comes with its own risks and downsides.

But back to the study. The researchers also found that “up to” 35% of patients had no relief. So let’s say about 30% of surgeries failed. That’s a lot of time, trouble, and money for no result – especially considering that these patients have (hopefully) tried several other treatments already.

Why did the surgeries fail? It’s hard to tell from this review alone, but researchers found some common reasons:

The trigger points were not all dealt with. This could mean that the surgeon simply hadn’t detected all the problem areas, or that the surgery did not successfully relieve them.
Migraine headache was triggered from new trigger points after the surgery, or it was triggered again from the old trigger points (the success of the surgery was temporary?).
For an unknown reason, the surgery simply did not relieve the migraine attacks.

There is only so much you can do about #3, because it’s unknown. The second point is tricky as well, because we may not know ahead of time how the body will respond to the surgery.

To a certain extent, the first point can be addressed by finding a specialist with considerable experience in migraine surgery – a specialist who will take the time that is needed to get the surgery right.

But all that being said, it still seems to be common wisdom to find a good specialist and investigate other treatments before trying surgery. The search for a good treatment will likely take time – don’t expect a “cure” in two months. Being patient and going to an experienced headache specialist in the first place will greatly increase your chances of success.