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15 September 2014

Migraine Surgery – Should it be Banned?

The debate about migraine surgery is nothing new, but it shows no signs of going away. Researchers in Germany recently fired a shot at migraine surgeries, using strong words starting with the title of their editorial, published in the journal Cephalalgia, Surgical treatment for migraine: Time to fight against the knife.

Their article, which you can read for yourself, doesn’t hold back in criticizing treatments and studies that involve surgical intervention for migraine patients. They mention the dreaded word “placebo”, doubt if “treatment-refractory” migraine patients even exist (patients who don’t respond to treatment), conjure up images of Europeans gazing in horror at American websites about migraine treatments, and talk about the horrible effects that surgery can have.

Even if the authors of the article manage to offend just about everybody, their article should not be quickly ignored.

Sadly, there is an impression that when “all else fails” at least there’s a way to deal with the problem through surgery. Sure, it may be serious, but so is my pain.

But it’s not that simple. Surgery is no guaranteed cure for migraine (well, it’s not a cure at all – but there’s no guarantee that it will take the symptoms away), and surgery itself can cause more problems. And yes, those problems can be serious.

Authors Hans-Christoph Diener and Ulrike Bingel are right about one thing – the evidence for many – most migraine surgeries is not strong. Doctors are right to put surgery way at the bottom of the list of treatments to try for migraine.

There’s no doubt that many patients do not respond well to some migraine treatments. It takes many people many years to find a good treatment, if they find one at all.

But we can’t automatically assume that surgery is always out there, waiting to solve our problems once we’ve tried x number of medications.

Should we continue to study surgery as a migraine treatment? Many researchers think so, just as we should continue studying many migraine treatments. And no one that I know of is calling for a ban.

But we do need to take a closer look at the evidence before we recommend surgery to any patient. That means understanding the clinical trials, but also understanding the medical history of the patient, and taking time to understand which treatments have the best chance of working.

That’s what we all want, isn’t it?

Meanwhile, if you’re considering surgery for migraine, it’s worth your while taking a look at Diener and Bingel’s thoughts.

12 September 2014

Football Helmets and Sports Concussion

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The debate about concussion in sports continues to heat up. Recently FIFA’s medical committee chairman, Michel Dâ€™Hooghe, recommended that games be stopped for three minutes so that players could be properly assessed for brain injury (that is, concussion). Meanwhile, Will Smith and Gugu Mbatha-Raw are set to star in a new movie about concussion in the NFL.

The controversy about football helmets isn’t over either. On the one hand, some studies seem to show that helmets can protect players from concussion to some extent, while some experts claim that the protection is minimal to none.

Virginia Tech has come up with a five star rating system for helmets, based on testing both on the field and in the lab. Certain helmets, such as the Schutt AiR XP Pro VTD and Riddell 360, for example, far out-performed the Schutt Air XP Ultralite and Riddell Revolution IQ.

To see the ratings, visit Adult Football Helmet Ratings – May 2014.

Although ratings are helpful, players need to know one thing above all the controversy and hype. If you’re playing a contact sport, especially sports like American football, hockey or rugby but including sports like football/soccer and basketball, you’re in danger of brain injury. Even if you buy the best protection, it won’t protect you anywhere close to 100% from concussion.

Does that mean don’t play the sport? Not necessarily, but it does mean that you can’t keep your brain from banging against the side of your skull using a helmet. That’s why there is a call for proper assessment of injuries, the need to visit a doctor or specialist, the need to get out of the game when there is an injury, and to think carefully before you put yourself in danger again.

There are also movements for better training on how to tackle, and better rules to protect players. (See the ideas from one specialist here)

The bottom line? Get the best helmet you can, but don’t trust it to protect you from concussion, a brain injury which can have consequences for years ahead.

For more thoughts, see this recent news report (video and article): High school football helmets tested for concussion risk See also this article on Head sports trauma

10 September 2014

Is it Concussion or Migraine?

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If you’re dealing with headache symptoms, and you suspect you may have had a concussion, it’s natural to ask – is it concussion or migraine?

First, some important background. Many people don’t realize that concussion is a brain injury. It’s important to start here, because there are still those who think that concussion is a minor, temporary injury.

Although some injuries are certainly worse than others, a single concussion can lead to long term problems. For more see Is it a Concussion or a Brain Injury?

So back to our question. Concussion can lead to something known as post-concussion syndrome (PCS). In PCS, although the concussion (read: mild brain injury) may have happened several days or even weeks ago, you start developing symptoms such as dizziness, fatigue, headache, anxiety, and insomnia. (More about post concussion syndrome symptoms here)

Now PCS can indeed look a lot like migraine, and sometimes it is difficult to know the difference. In fact, some might say that PCS is triggering actual migraine attacks.

But more likely when you ask if it is concussion or migraine, you’re asking if the concussion is at the root of the problem, and if you should be looking for treatment that is different from typical migraine treatment.

How to tell if you have PCS: Here are some important clues. First, in order to be diagnosed with PCS, your symptoms must be new. These symptoms usually appear between a few days and four weeks of the concussion. So if you’re having the same symptoms as before, you probably won’t be blaming them on the concussion.

If, however, you had struggled with headaches before the concussion, but your symptoms have changed, you may have PCS. You should see a doctor without delay.

After you have confirmed that your symptoms are new, or that they have changed, your doctor will want to know more about they symptoms you’re experiencing, when they started, how severe they are, and so on.

If you decide after speaking with your doctor that you don’t have PCS, you still need a proper diagnosis for your symptoms. There are various types of headache, and even various kinds of migraine. Getting a specific diagnosis will help you find treatment that will be effective.

For more information, see Post Concussion Syndrome – causes and treatment

8 September 2014

Are Clinical Trials Still Being “Hidden”?

James Discoveries & Stats, News 2

Research in the USA is confirming what studies in the British Medical Journal have already pointed out. Clinical trials, once completed, are not coming to light for months – even years. And so neither health professionals nor patients are getting the whole story.

Studies that we talked about in 2012 found that many studies were not published even four years after they were completed. Read the full story at: The Case of the Missing Studies: Patients missing critical information.

But researchers from the California Pacific Medical Center Research Institute and University of Rochester School of Medicine and Dentistry set out to discover if this is true of migraine trials in particular. Their findings are disturbing.

The short answer is that yes, the situation is the same with migraine trials. Of 163 trials that were searched, only 57% were available in peer-reviewed literature after 12 months. Searching other literature brought the number up to 70%. Where are the other 30%?

Migraine Trial Availability
Now it appears that migraine trials have a better record than studies for some other diseases. However, various studies that have investigated this phenomenon have different numbers because of different methods.

The bottom line is this: If you’re looking for migraine or headache trials in the typical places, a huge percentage of trials won’t be there.

This particular study did note that sponsored studies, for example studies sponsored by a big drug company, were actually more likely to be published. Although this doesn’t completely let drug companies off the hook, it does suggest that organization, finances, and public scrutiny, may help to get a trial from start to published.

What kinds of trials are missing? Two kinds in particular, according to the study’s authors.

First, small trials. Trials with fewer than 141 subjects were less likely to be promptly published. Typically, these trials are less valuable than larger studies. But they are also easier to do, and often very well designed. So in some cases these studies are actually more useful than larger studies.

Second, trials with negative results. This is a well known problem. Maybe there are 10 trials on a certain migraine medication. Four show positive results, six no results at all, or negative results. What if three of the six were never published? It sure gives us a different picture, doesn’t it?

Add this to the fact that drug companies are naturally going to promote more positive studies, and all of a sudden you have a “miracle pill” that should take care of almost any migraine! Except that the studies really aren’t saying that.

This is a very challenging problem to solve. To have well-designed, well-reported, honest trials, you need oversight and accountability. And this means world-wide oversight and accountability. But there are biases and politics in every country, and even world-wide.

Medical research has come a long way, and international cooperation is allowing us to learn more than ever before. Unfortunately, in order to make good research happen, you still need education, honesty, and money. Even then, human researchers are not perfect.

The authors of this study, who have studied this area for a long time, make some suggestions about how the system can be improved.

Meanwhile, doctors and patients need to be aware that studies are a tool, not an infallible standard. Treatments which are studied (whether drug or non-drug) are likely not as great as they may seem.

To read a summary of this study, see How transparent are migraine clinical trials? For the full report, see the article at the journal Neurology.

5 September 2014

Migraine Awareness Week 2014

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Next week is Migraine Awareness Week in the UK. This is a great opportunity to spread the word about migraine and its related disorders.

The Migraine Trust, who promotes the event, has done a lot of work to find better solutions for the workplace and the school room. If you’d like to know more, visit the Migraine Trust website, or find them on Facebook or Twitter. There will be a migraine Q&A on Twitter with Dr. Mark Weatherall, consultant neurologist to the Imperial College Healthcare and Ealing Hospital NHS Trusts, on the 9th of September. Visit the Migraine Awareness Week page for details.