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When Taking a Shower Hurts: Migraine and Depression

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Taking a shower can be pretty painful for some people during a migraine attack. And I’m not necessarily referring to migraine pain. I’m talking about allodynia.

When taking a shower HURTS!Allodynia – in this case, cutaneous allodynia, is a strange discomfort and/or pain on the skin, for no normal reason. The slightest touch can cause this pain – wearing jewellery, even standing outside on a windy day – or taking a shower.

It’s a fairly common symptom of migraine, affecting about 2/3 of us, and more common in women (although I have had the dubious pleasure myself).

Sometimes, allodynia is a warning sign, coming before the headache phase of the migraine attack. Repeated episodes of allodynia may also signal a future worsening of migraine, from episodic to chronic.

Researchers in Korea studied 332 patients to find out what other issues may be comorbid with allodynia – what did patients with allodynia have in common?

They found that fewer Korean patients seemed to suffer from allodynia than expected, but there was still a large enough group to draw some tentative conclusions.

As with previous studies, they confirmed that the symptom was most common in women. But they also found that allodynia frequently went along with major depressive disorder. Chronic migraine was also present in many patients, as well as sensitivity to light.

Depression continues to be a tricky thing to understand when it comes to migraine. Although certainly migraine symptoms may make you depressed, there seems to be something else going on that makes the depression worse than expected in some people. The commonality of allodynia and depression may give us further clues into the connection.

As we continue to study, be sure to mention as many symptoms as you can to your doctor. Depression, allodynia, and other symptoms and conditions may help her treat you better. Although some medications may better help patients with allodynia, it’s important to treat migraine – and depression – as a whole, in order to get rid of this possibly disabling symptom.

For more on cutaneous allodynia, check out My Hair Hurts! Migraine and Allodynia.

Also see the study abstract here: Cutaneous Allodynia and Its Risk Factors in Korean Patients with Migraine: A Survey of Two Tertiary Care Hospitals. Another in-depth article on allodynia: Cutaneous Allodynia in the Migraine Population

MSG, Migraine, and New Treatments

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A new study is giving us further insight into the migraine-MSG connection, and may be another step to better migraine treatment in the future.

Recently we talked about a non-traditional migraine treatment – ketamine. Ketamine is a NMDA (N-methyl-D-aspartate) receptor antagonist, which means that it blocks a certain receptor that plays a part in the migraine chain-reaction. Memantine is another example.

Migraine is actually a complex web of cause and effect. So various treatments attack various parts of the migraine system.

MSG: Why does it trigger migraine attacks?What does all this have to do with MSG? MSG, or monosodium glutamate, is a common additive to foods which seems to trigger migraine symptoms in some people. Researchers in Canada decided to investigate further. In a report published in Neuroscience in October, they explained that MSG given to rats actually activates peripheral NMDA receptors, leading to migraine symptoms.

This may be another bit of evidence telling us to avoid MSG, but it’s actually much more than that.

It further confirms what scientists have suspected for many years – the NMDA receptors can play a key role in migraine disease. And so it may be that NMDA receptor antagonists are worth more serious research.

While older drugs like ketamine may help some patients, the side effects put them a long way down the list for most people. But if we could develop a similar drug with fewer side effects, it could help a lot of people who, up to this point, have not found a good treatment.

For more interesting information about NMDA receptors, and the connection between epilepsy and migraine, see Common Pathophysiologic Mechanisms in Migraine and Epilepsy. For more on how to spot MSG in foods, see The 12 Top MSG Offenders.

CGRP Inhibitor Race

Approaching the Finish line: CGRP Inhibitors

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For the last few years we’ve been watching the race to get CGRP inhibitors on the market for migraine prevention. Well, you could be seeing those drugs approved as early as next year. What’s the latest?

First, if you need to review exactly what CGRP inhibitors are, check out The Secret of CGRP.

CGRP Inhibitor RaceLeading the pack at the moment is erenumab, also known as AMG 334. In September, the report said that 70mg of erenumab, delivered by injection, had almost 3 fewer days of migraine attacks per month. These are episodic migraine sufferers who originally had between 4 and 14 migraine days per month. That means that if you could have about 30% fewer attacks, and side effects seem to be few.

Erenumab now moves into the second part of the trial, testing different dosages over 24 weeks.

Also in Phase III trials is galcanezumab, also known as LY2951742. Galcanezumab also had statistically significant results in previous trials, with a once-a-month injection, and participants are currently being recruited for new trials – those with chronic and episodic migraine, and those with chronic and episodic cluster headache – for more information visit ClinicalTrials.gov.

A little further behind, but possibly the one to watch in 2018, is TEV-48125. A once-monthly injection at various doses was tried, and as early as 3 days into the treatment patients had positive results. Studies continue for both chronic and episodic migraine.

Finally, let’s not leave out ALD403. ALD403 is well on its way for treatment of episodic and chronic migraine, though the episodic migraine trials are further along.

Many patients taking ALD403 in trials actually experienced a complete remission of migraine, and others a significant decrease. Trials continue.

These are just tidbits of information about the trials, and they really can’t be compared at this point, even if we did have all trial data. The point is that these still look like solid options to prevent episodic and chronic migraine, and even cluster. Some if not all of these should roll out over the next 2-3 years, and by that time we’ll know them better.

For more information, see:

Ketamine: An Option for Migraine and Depression?

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Yes, with cautions.

It’s been a while since we talked about ketamine for migraine (see Watch for it – Ketamine for Migraine and More), but the NMDA (N-methyl-D-aspartate) receptor antagonist is still gaining ground as a possible treatment for migraine and depression.

Non-traditional Medication ReportKnown on the street as a date rape and club drug (one especially easy to overdose on), ketamine is actually an anaesthesia medicine that has also been used for chronic pain conditions and depression.

Compared to illegal use and aesthetic use, the dosages are quite low, and usually done in conjunction with other treatments under close doctor supervision. But it could be a real help to people who have a combination of symptoms/diseases (such as migraine and depression) or those who have not responded well to other common treatments.

Ketamine was discussed in two separate sessions of the American Academy of Pain Management 2016 annual meeting. Dr. Duren Michael Ready, a headache specialist at Baylor, Scott & White Health in Texas, reported on research supporting the use of a 10-50mg dose given by nasal spray to migraine patients. This dosage seemed to reduce migraine aura, and at the higher level (50mg) treat depression that hasn’t responded to other treatments.

Dr. Ready emphasized that it’s important to use alongside preventative measures, so that it will be used as little as possible.

Dr. Ben Keizer, also in Texas, spoke on the use of ketamine for complex regional pain syndrome (CRPS) and post-traumatic stress disorder (PTSD). In these cases, the treatment can also combat headache, which is one of the possible symptoms. It may be that ketamine could help with other comorbid conditions such as fibromyalgia and IBS.

Although the doses are not high enough to sedate patients, some do experience hallucinations or an “out of body” experience, even though the dosages are low.

With caution and at lower doses, ketamine is being used to help certain migraine and headache patients. Have you been prescribed ketamine? What was your experience?

For more, read Ketamine May Treat Migraine, Chronic Pain.

Predicting: Will This Medication Work?

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Which would you prefer?

  1. You walk into the doctor’s office, and the doctor offers you a medication that happens to interest them at the time.
  2. You walk into the doctor’s office, and the doctor offers you the medication that works with the highest percentage of patients with your condition.
  3. You walk into the doctor’s office, and the doctor checks your statistics and offers you the medication that is most likely to work for you.

I don’t know about you, but I would sure prefer #3. I would take a well-educated #2 if I couldn’t get #3. (And frankly, there are worse things than #1.)

Migraine Medication PredictionsAt this stage in migraine research, with a good specialist you’ll hopefully get a combination of #2 and #3 (and likely a pinch of #1). But researchers are trying to gather the information we need to offer more customized treatments.

As we gain the ability to gather more information about ourselves (e.g. FitBit and Migraine), the possibility of fitting the treatment more exactly to the patient is becoming a reality.

Perhaps a more immediate benefit is avoiding treatments that aren’t likely to work. Today, there are so many migraine treatments that a patient could spend a lifetime trying them – why start with treatments that probably won’t work because you’re a) a women or b) diabetic or c) suffering from a certain symptom?

A recent study in the USA studied responses from 8233 patients with episodic migraine to see which variables could predict whether or not an abortive treatment would work. Typical go-to medications for migraine are the various types of triptans.

So here’s the question – what types of things should a doctor know, that may predict whether or not a typical abortive treatment will work?

First, symptoms.

  • How intense is the headache?
  • How frequent are the attacks?
  • Does the patient suffer from cutaneous allodynia?
  • How intense are the symptoms overall?

Second, medical profile.

  • What comorbid conditions does the patient suffer from? Do they suffer from depression, for example?
  • Are they taking preventative medications (for migraine)?
  • Are they overusing any medications?

Finally, certain basic factors come into play, such as

  • Gender
  • Body mass index

These and other factors may help us better customize your treatment in the future.

In the mean time, the more information you can keep track of (don’t let it take over your life) the better. Keep in mind your medical history (and family medical history) as well, which can help your doctor a great deal.

To read the abstract of this study, go to Predicting Inadequate Response to Acute Migraine Medication: Results From the American Migraine Prevalence and Prevention (AMPP) Study from the October 2016 edition of Headache.

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