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Posts by James Cottrill:

20 September 2024

Ultrasound for Migraine?

Most of us are somewhat familiar with ultrasound for imaging – such as the ultrasound images you may see of your baby while you’re waiting for the big day.

Ultrasound has also been used in physiotherapy, though you may have read some doubts about the usefulness of it.

But an emerging treatment is what is called transcranial-focused ultrasound. There is both high and low-intensity focused ultrasound, but in this case we’re talking about the low-intensity kind.

We are already familiar with devices that are used to lessen or even prevent migraine symptoms. Transcranial magnetic or electric stimulation/modulation has become quite common, in fact. So you can think of focused ultrasound of a way to do something similar – treating symptoms directly in the brain. So why do we need something new?

The advantage of focused ultrasound is that it seems to be very . . . well, focused! The challenge with any treatment is making sure it gets to where it’s needed, and only where it’s needed, in the most efficient way possible.

A recent study in the journal Pain explains in this way:

The ultrasonic intervention is conceptually related to TMS applied to the motor cortex, which can provide improvements in chronic pain in certain groups of patients. The key difference is that ultrasonic waves can directly modulate the deep brain regions involved in chronic pain, including the ACC. Transcranial magnetic stimulation is believed to modulate deep brain regions only indirectly, which may contribute to its variable response and the need for frequent re-administrations.
Noninvasive targeted modulation of pain circuits with focused ultrasonic waves

(the ACC – anterior cingulate cortex, a region of the brain.)

So, in other words, the ultrasound may turn out to be more direct and efficient. The researchers go on to say that this treatment may actually work well with TMS (transcranial magnetic stimulation).

This kind of research is actually several decades old, but it has been the focus of newer research. It’s non-invasive and seems to have minimal, temporary side effects if any. Using focused ultrasound on the brain and the spinal cord may actually have potential to treat other types of pain as well (see Focused Ultrasound (FUS) for Chronic Pain Management: Approved and Potential Applications).

For more, check out Focused ultrasound to specific brain regions relieves pain.

5 September 2024

Vestibular Migraine and Additional Symptoms

James Discoveries & Stats 0

A new study is helping us to further understand vestibular migraine (VM) and related types of migraine. The study, published this spring, tried to identify more specifically some of the symptoms that patients with VM experience.

Understanding and identifying these symptoms will help you and your doctor find better treatment. Let’s take a quick look at what the study found:

Ongoing Dizziness?

Officially, vestibular migraine involves temporary symptoms, lasting during part of or all of your migraine attack. However, the study found that many patients experience at least some level of dizziness between attacks. In fact, almost half reported almost constant dizziness. The researchers suggested that this should not lead doctors to write off VM as a diagnosis.

Persistent Postural-Perceptual Dizziness (PPPD)

The researchers define PPPD in this way:

This disorder presents with non-spinning vertigo, dizziness, or unsteadiness occurring on most days for at least 3 months, and worsened by movement, upright posture, and exposure to moving or complex visual stimuli.
Beyond Vertigo: Vestibular, Aural, and Perceptual Symptoms in Vestibular Migraine

It looks like PPPD may often go hand in hand with migraine (about 1/3 of patients with PPPD also have migraine) – especially VM (about 17%). In fact, knowing that VM patients may have symptoms between attacks, the two disorders may “blur” into one another, being confused.

Mal-de-Debarquement Syndrome (MDDS)

Literally “landing sickness” or “disembarkment syndrome”. You know how you get off the boat and you feel like you’re still moving? This goes to extremes in people with MDDS. In fact, some patients just develop it for no known reason, spontaneously. Patients with MDDS do indeed have a higher likelihood of migraine.

Tinnitus

Tinnitus is a perception of noise in the ear, often a “ringing”. 25-50% of VM patients report tinnitus. Tinnitus can be very difficult to treat, but researchers point out that some patients do indeed improve when they treat their migraine attacks.

Other Hearing/Ear Issues

This would include a sense of fullness in the ears, noises in the ears, or actual loss of hearing. Many of these things do seem to be linked to migraine, and again, treating the migraine may also treat the hearing disorder.

Perceptual Symptoms

Once again, we’re putting a whole range of symptoms under one title. This would include things like feeling like things are out of proportion, farther away or closer. It could also be the feeling that time is moving too fast or too slowly. There may even be visual distortions, kinds of hallucinations. There’s a long and fascinating list in the study under this heading.

Many of these symptoms may be a part of a migraine attack, but there could also be another underlying symptom.

Why This is Important

It’s important to know the various common symptoms so that you can notice them in yourself or a loved one. With the pain of migraine, it’s very easy to overlook other symptoms, especially if they seem to persist even when you don’t have a headache.

Noticing these symptoms can help in two ways:

You may have another condition, which will require a unique treatment.
You may benefit from a specific migraine treatment that will help with these specific symptoms.

Doctors should take a look at this study if they have patients with migraine, and especially VM. But patients should be aware as well of the value of recognizing and naming any symptoms that they notice.

The researchers say it this way:

Vestibular migraine is an underdiagnosed disorder. It may present with a wide range of symptoms, but only a few are represented in the diagnostic criteria. Familiarity with the other non-vertiginous symptoms may help clinicians recognize this diagnosis more often, especially when vertigo is not the patient’s main concern. As many of these symptoms may present in migraine more generally as well, knowledge of the broad range of possible presentations should improve patient care. Many patients who could benefit from migraine therapy will be missed if only the most common migraine symptoms are assessed.
Beyond Vertigo: Vestibular, Aural, and Perceptual Symptoms in Vestibular Migraine

27 August 2024

Do You “Hide” Your Migraine Attacks? (Of course you do…)

James Discoveries & Stats 0

A study in Japan about migraine stigma was recently published in the journal Brain and Behavior. And the more I think about it, the more surprising the results are.

The study focused on migraine-related stigma (MiRS), asking questions about work, family, and school. Does your employer minimize your migraine attacks? Do you hide your migraine attacks from others? Have you ever been accused of being a “drug seeker”? Has this caused problems in your marriage? Have you ever lost a job due to migraine? Have you ever had to ask someone to adjust your schedule because of migraine? And so on.

You can read the details of the study for yourself. Most of it isn’t too surprising. For example, about half of the people with migraine felt that their employers were not very understanding regarding their condition.

But the conclusion of the authors was quite interesting. At first, the burden of migraine on society didn’t seem too high. A lot of people responded that they didn’t even know a person with migraine. And although there was stigma, it maybe wasn’t as high as one might expect.

But then they took note of something else – many migraine patients hid their migraine attacks from others.

In other words, it wasn’t so much that it wasn’t a “burden” on society – it was likely more that people didn’t realize how much of an issue it actually is.

Now, the researchers found that over 1/3 of patients sometimes or even very often hid their migraine from coworkers. Really? Only 1/3?

It sounds bad to “hide” something, doesn’t it? And it can be, if you’re hiding it because other people are going to misunderstand, or misjudge you. Or if you’re just lying straight up.

But on the other hand, we know that migraine can make other people uncomfortable. If you can somewhat hide your pain, that’s not always a bad thing.

So there are many, many reasons to “hide” a migraine attack. I’m not recommending you do it, I’m just saying that – I find it hard to believe that only 34 or 35% of a group of migraine patients ever “hid” their attacks. It’s probably the way the question was asked. It’s one thing to admit you have a migraine, it’s another thing to really explain how bad it is! So I imagine most people hide somewhat most of the time.

So I want to hear your comments. Do you…

…hide the fact that you’re having an attack?
…minimize just how bad it is?
…complain a lot less than you really want to?

…and if so, why? For example,

…you’re afraid that people will think it’s “your fault”.
…you’re afraid of losing a promotion/job/project/status?
…you don’t want people around you to be uncomfortable?
…you’re afraid that people will treat you differently? How?
…you’re embarrassed?
…other?

5 August 2024

An MRI for Migraine?

James Discoveries & Stats 0

So this is a “holy grail” of migraine diagnosis – that is, something that we’ve always wanted to be able to do. But – we haven’t quite found it yet. Or have we?

Let me explain. When a patient comes into a doctor’s office with a broken arm, the doctor can check how your muscles and joints are working, ask you where the pain is, and even take an x-ray. The result is pretty straightforward – you have a broken arm.

But migraine – and remember, there are various types of migraine, and migraine is only one type of headache disorder – is entirely different. Your doctor relies mostly on what you say (especially if you’re not in the middle of an attack right then) – how you describe the pain, what other symptoms you’ve noticed, and so on. They don’t generally give you a scan, or take a blood test.

Don’t blame your doctor for this – these tests wouldn’t usually be of any help, and in some cases might do more harm than good.

Migraine is a complicated disease. We don’t entirely understand why an attack happens. And although we’ve learned a lot about what happens in the body when an attack takes place – we can indeed see certain things happening with various types of technology – we still don’t understand why some people have migraine and others don’t. We have a lot of ideas, theories, and clues – and even a lot of knowledge – but we don’t have the whole picture.

So researchers are still trying to find a way to do test of some kind – to look at something in your body – that will tell them – yes, this person has migraine. Better yet, this person has this type of migraine. That way we would be able to get to the best treatment for you ASAP.

One of those bits of research was just published in June. It involved a type of MRI scan (magnetic resonance imaging scan) called diffusion-weighted imaging (DWI).

DWI is a type of scan that can “see” where water molecules are. Here, let’s let Dr. Alexander Mauskop from the New York Headache Center explain:

The researchers used diffusion MRI, a technique that focuses on the movement of water molecules within the brain’s tissues (fMRI measures blood flow to different areas of the brain). It is particularly useful for mapping the brain’s white matter tracts, which are the pathways that connect different brain regions.
Another MRI study attempts to diagnose migraine

So, as you would normally do in a study like this, they took patients with migraine, and patients without migraine, and compared the two. And yes, there tended to be a difference. Back to Dr. Mauskop:

Significant differences were found in brain regions such as the orbitofrontal cortex, temporal pole, and sensory/motor areas.

Changes in connections between deeper brain structures (like the amygdala, accumbens, and caudate nuclei) were also noted.

Using machine learning, the researchers could distinguish between migraine patients and healthy individuals based on these brain connectivity features.
Another MRI study attempts to diagnose migraine

That sounds pretty amazing, and it actually is. One of the beauties of computer technology is that computers can play with huge quantities of numbers – lots of data – and quickly compare things in a way the human brain can’t.

But don’t run to get your head scanned yet. Your doctor will still probably get a more accurate diagnosis by talking to you. Why?

First, this was a fairly small study. Will this difference continue in other groups of patients? Why the difference? Would there be a difference between patients with migraine and other different headache conditions? Or other conditions in general? And even if we can accurately predict that a patient has migraine, will this be more accurate than a well-informed specialist and a patient who communicates?

We hope that this research will continue, because it would have huge benefits. Meanwhile, instead of getting your head scanned, make sure you have a doctor who takes the time to talk to you. Consider a headache specialist. And watch your symptoms closely – tell your doctor what you’re experiencing, and be sure to share your medical history. Becoming adept at these things today will in most cases do a lot more than having a scan.

27 July 2024

Another Weapon against “Rebound Headache”?

James Discoveries & Stats, Medications, Treatments 0

A major concern among migraine patients (and their doctors) is what we sometimes call “rebound headache” or “medication overuse headache”. The perhaps over-simplified idea is that taking “too much” medication may make your headache symptoms come back worse than ever, or more frequently.

But this explanation can be misleading, partly because the whole concept remains very controversial. Just which medications lead to more headaches? And if migraine medication “causes” migraine, what’s the treatment?

In spite of a lot of misunderstanding regarding these types of migraine attacks, the ultimate goal really isn’t to take “less medication”. The goal is – you guessed it – less migraine! If you’re taking a painkiller or migraine medication and your symptoms are worsening over time, it may simply be time to try something different. Even if you end up taking more pills, you may be able to start a trend of fewer and fewer headaches.

How so? For example, if you find yourself taking a painkiller or more every single day, and your headaches are only getting more severe as the months pass, not to mention side effects from the medication, one option is to try a daily preventative – something that has been tested properly specifically as a daily medication.

Though information is limited about certain types of medication for certain types of migraine, every once in a while a study comes out that prioritizes a certain kind of medication for a certain type of migraine – such as rebound or medication overuse. And that’s the case with a study published in the journal Neurology last month.

The drug is atogepant, a calcitonin gene-related peptide receptor antagonist, sold under the brand name QULIPTA (you can read more about atogepant here). It’s a preventative taken orally each day. And in spite of the fact that rebound type migraine attacks are notoriously difficult to treat, atogepant seems to make a significant difference.

In the study, patients took one or two dose per day (it was the same amount either way – 60mg total). Patients had 2-3 few days a month with migraine, and 3 fewer days with other medications. For those with medication overuse headache, that means about a 50% reduction in headaches for almost half of the patients. Many of the patients actually no longer met the official criteria for medication overuse headache by the end of the study.

The best results overall came for patients spreading out the daily preventative in two doses.

Once again, this is not a silver bullet that works for everyone. But the results are very good considering how difficult this type of condition can be to treat. Study author Dr. Peter J. Goadsby notes:

Based on our findings, treatment with atogepant may potentially decrease the risk of developing rebound headache by reducing the use of pain medications. This could lead to an improved quality of life for those living with migraine.
Dr. Peter J. Goadsby

This is one of those clinical trials that, although preliminary, can be useful immediately. Any medication showing positive results for medication overuse is worth moving up the list for those who are struggling with increasing headache and migraine symptoms.