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18 April 2017

Migraine and TMD: A Complex Relationship (that should not be ignored)

James Discoveries & Stats, Information 3

Although it’s not news that there’s a relationship between migraine and TMD, it might be a surprise just how complex the relationship is.

TMD refers to temporomandibular disorder/dysfunction, actually a group of disorders that affect (but are not necessarily caused by) the temporomandibular joint (TMJ) and surrounding muscles, nerves, and tissues. TMD may be caused by an injury or a disease such as arthritis. There may also be a connection with structural issues, and even clenching and grinding of the teeth while you sleep.

TMD and Headache — Illustration courtesy Patrick J. Lynch

TMD is actually very poorly understood, and there is a lot of controversy about what causes it and how to treat it in specific cases. But when you think about the structure of the jaw, joint, and the trigeminal nerve system, which is all connected, it’s not surprising that researchers have been very interested in the connection between TMD and headache disorders. That nerve system may play a key role in starting headache pain in migraine disease. It seems that the way trigeminal pain is processed can become impaired, leading to a worsening of migraine. The new class of drugs (CGRP inhibitors) currently being developed play a role in controlling trigeminal pain messages.

A 2016 study concluded that the connection between migraine and TMD was complicated further because of other physical symptoms, and the presence of bruxism (clenching/grinding teeth during sleep). Researchers concluded that doctors need to treat both headache/migraine and TMD together.

A study earlier this year asked the question – can the presence of headache disorders, such as migraine, actually predict TMD? In other words, even though migraine may/may not directly cause TMD, does the presence of migraine or another headache disorder tell us that the patient has a good chance of getting TMD later on?

The answer was yes. Patients who had no sign of TMD, but who did have a headache disorder, were far more likely to end up with TMD. The headache condition also tended to worsen in patients who eventually had TMD symptoms. Patients frequently ended up with migraine and TMD.

Researchers again affirmed what I mentioned in our last podcast – headache conditions, migraine in particular, need to be treated (Migraine and Generalized Anxiety Disorder). If they aren’t, they may lead to other conditions. One of those conditions is TMD. And what if the presence of new TMD in turn worsens the migraine? That could may migraine more difficult to treat.

The relationship between TMD and migraine is complex. It’s not a simple case of one causing the other. There may be underlying causes of both.

Doctors and patients need to focus on treating both, and being aware of changing and worsening symptoms so they can be caught early. If migraine or TMD are ignored, or just treated with “painkillers”, patients may find themselves with more pain in the end.

3 April 2017

Vestibular Migraine: What’s New

James Discoveries & Stats, Information 0

Dizzy? Maybe have some migraine symptoms? It could be vestibular migraine.

We’ve been talking about vestibular migraine here for almost 10 years. Back then it was not even recognized by the International Headache Society as a distinct type of migraine. So we talked about it as a manifestation of various types of migraine. In fact, dizziness/vertigo are very common migraine symptoms.

Because, after all dizziness and vertigo (yes, I know the two are different) are seen in more than just one type of migraine. But today vestibular migraine is much more recognized as a distinct type of migraine.

So what is it, and how are people diagnosed?

First, you need to have a past history of some type of migraine. Second, some of your attacks (at least 50%, say the official guidelines) should include at least one common migraine symptom: sensitivity to light or sound, visual aura, and/or a significant headache, usually one sided and throbbing.

Finally, the vertigo/dizziness. It will be significant enough to interfere with your normal activities. It will last between 5 minutes and 72 hours.

You can probably already see some reasons why there is still so much confusion. If some other types of migraine also may include dizziness (such as migraine with brainstem aura) – not to mention other conditions – and if you already have migraine, and you have these symptoms sometimes, but not all the time – well, it can be a challenge to diagnose.

Even if the vertigo/dizziness accompanies your migraine attacks, your doctor should check carefully for other conditions that may be the underlying cause. And, of course, if you do have a history of migraine, and/or are experiencing any of the symptoms above, your doctor should know that as well. It’s easy to misdiagnose vestibular migraine as something else.

The current research into migraine and dizziness is being put to good use. Take for example recent studies into vertigo in children. It has been discovered that many children with vertigo actually have migraine, and that when the migraine is properly treated the vertigo is also treated. The same, of course, would be true for adults.

And beyond migraine treatment, some patients are finding help in “vestibular rehabilitation”, specific therapy for people with vertigo/dizziness.

Another very common cause of vertigo is benign paroxysmal positional vertigo (BPPV). There is some information and resources here.

Whatever the cause, the symptoms can be very disabling, and do need to be taken seriously.

You can help your doctor come to a correct diagnosis. Take note of how long the symptoms last, and what other symptoms you’re experiencing – such as ringing in the ears, visual aura (eg flashing lights), headache, or hearing loss?

Also, try to be more specific than just “I feel dizzy”. Does the room seem to be spinning? Do you feel like you are moving? Does moving make it worse?

And, as always, make sure your doctor knows your medical/family medical history.

It’s encouraging to see a renewed interest in research of vestibular migraine. However, it is a very difficult condition to study, and we still know very little about it. The good news is that many patients are finally getting an accurate diagnosis, and are finding migraine treatment that works.

30 March 2017

PFO Closure for Migraine: An Update

James Discoveries & Stats, Information 9

12-14 years ago, there was a lot of discussion about “PFO closure” for migraine.

PFO stands for patent foramen ovale, a hole in the heart between the right and left chambers. A PFO is a common developmental condition, affecting about 1 in 4 people. But you may never know you have it.

patent foramen ovale Surgery can be done to close the PFO, for example if someone has low blood oxygen levels that may be caused by the defect. But years ago, patients who had the surgery for various reasons began to report that their migraine attacks had also subsided.

And so began the investigations and the trials. The well known MIST trials, originally planned as a series of four trials, were cancelled before the second one was completed. The results were not encouraging.

More studies have been done recently, and results continue to be mixed at best.

So why is PFO closure still being discussed? First, because some patients do experience a reduction in migraine symptoms after PFO closure. Second, it’s clear that migraine and PFO are somehow linked – PFO patients are much more likely to have migraine, and migraine patients are more likely to have PFO.

But a relationship does not mean that fixing one problem will fix the other, as trials have shown.

But there is more. For example, particles that move from one side of the heart to the other (through a shunt) may lead to migraine – not to mention the relationship between stroke, PFO and migraine. These particles in the blood may trigger a cortical spreading depression, a key part of the migraine chain-reaction.

In short, there are good reasons to think that PFO may actually increase migraine attacks.

So why doesn’t everyone with migraine just have the surgery? There are actually good reasons. And this has been one of the downfalls of the trials – patients simply don’t want to have heart surgery – even if it’s fairly simple surgery.

Though the surgery is generally safe, there are risks. In a report published earlier this month, PFO and Migraine: Is There a Role for Closure?, the authors noted that “several potentially life-threatening procedure-related adverse events occurred in the clinical trials”. There are also concerns that the surgery may lead to other health problems down the road.

Researchers remain intrigued by the possible connection between PFO closure and migraine. Although trials have been disappointing, it’s still worth trying to understand the connection, which may lead to other types of treatment. And it could be that we can find a certain type of migraine patient who will benefit from PFO closure, even if those are a small percentage of migraineurs.

But in the mean time, the poor chance of success, and risk of other health issues, and availability of many better treatments, continue to leave PFO closure in the area of research and not in the area of recommended treatments.

As the authors of the above say, although some patients who have the surgery for other reasons may see a decrease in migraine symptoms (either due to the closure or other reasons?), they “recommend against offering PFO closure as a preventive treatment for migraine”.

27 February 2017

Do Polarized Lenses make you dizzy, or give you headaches?

James Information 7

A quick search online will tell you that there are people concerned about getting dizzy, nauseous, or even experiencing headaches when wearing polarized lenses. On the other hand, a vast majority seems to find either no effect or even relief from headache symptoms while wearing polarized lenses. So what’s the story?

Polarized lenses - do they cause dizziness? Polarized lenses are used in some sunglasses in order to cut down on glare. Anyone who has experienced migraine knows that glare can be like a knife going through your head. Thus, quality sunglasses are popular with migraine sufferers.

Although those marketing sunglasses are naturally anxious to defend their products, there are good reasons to believe that the polarization itself, in a majority of cases, is probably not the culprit.

First, as already mentioned, migraine patients are much more likely to appreciate quality polarized lenses than to avoid them. Secondly, because quality sunglasses (such as these) tend to be expensive, cheap versions are often purchased which may have distortions in the lenses – and this certainly could lead to the symptoms mentioned above.

Also, any new lenses, especially (but not exclusively) prescription sunglasses, do take time to get used to. At first, any new lenses may cause some unwanted symptoms.

Do these things explain everyone’s complaints of headache or dizziness from polarized lenses? Probably not, which is why it may be something worth studying in a clinical trial.

However, for most migraine patients, quality polarized lenses are probably going to be a benefit, if you give them a little time. In fact, there are polarized lenses especially designed for migraine patients. And lessening migraine symptoms are not the only benefits.

Have you experienced any strange symptoms only when wearing polarized sunglasses? What have you done that has helped? Leave a comment!

9 February 2017

Women, Migraine, and Stroke

James Discoveries & Stats, Information 1

The link between migraine and stroke is nothing new, but recent research is making it a hot topic once again. In particular, there are increased concerns about the risk of stroke in women with migraine.

RISK For example, a study published last month in the American Journal of Medicine researched data on women who were evaluated for ischemic heart disease (“hardening of the arteries”). Of those women, anyone who had reported a history of migraine was at a higher risk of a “cardiovascular event” such as stroke or heart failure. (Study abstract: Migraine Headache and Long Term Cardiovascular Outcomes: An extended follow-up of the Women’s Ischemia Syndrome Evaluation.)

A study in Turkey (Istanbul University) focused on patients with their first stroke, between the ages of 15 and 50, compared to gender and age matched healthy patients. Frequency of migraine was almost double in the stroke patients. But when different types of migraine were compared, the results were much more specific. The only ones with an increased risk were women with migraine with aura. Another study in the American Journal of Obstetrics and Gynecology suggested that women with migraine with aura who also used hormonal contraceptives were at a significantly higher risk.

(See Migraine as a risk factor for young patients with ischemic stroke: a case-control study. and Use of combined hormonal contraceptives among women with migraines and risk of ischemic stroke.)

Another study out of Harvard University and Massachusetts General Hospital in Boston focused on those who experienced stroke after surgery – again, patients with migraine – especially migraine with aura – were at an increased risk in the first 30 days after surgery. (Migraines tied to increased stroke risk after surgery)

Each of these studies has its strengths and weaknesses, but the research continues to suggest that people with migraine, especially women with migraine with aura, have an increased risk of stroke.

It’s important to remember that this is not a high risk, in the sense that you’re just guaranteed to have a stroke. If you have migraine, chances are you won’t have a stroke any time soon. But, like smoking or a poor diet, migraine does increase your risk. It increases your chances.

So its all the more important to treat your migraine, and minimize other risk factors that you can control.

Finding good treatment for migraine may do more than just alleviate pain – it may decrease your risk of stroke. And some migraine-fighters, such as magnesium, may also fight stroke.

For more on migraine and heart disease, see Migraine and Heart Disease: 7 Critical Things to Know Now