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American Academy of Neurology

Migraine and Complications in Pregnancy

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A recent press release from the American Academy of Neurology reports on a study of women with migraine, and what kinds of complications they may expect during pregnancy. Should potential mothers be concerned? And what can they do to prepare in advance?

Pregnancy - migraine risks?

This study took a look at about 30,000 pregnancies in about 19,000 women. Over 2000 of those women had been diagnosed with migraine. So how did their pregnancies differ from the rest?

Researchers did indeed conclude that women with migraine were more likely to have certain complications:

  • Preterm Delivery – that is, delivery before 37 weeks.
  • Gestational High Blood Pressure – hypertension during pregnancy
  • Preeclampsia – another high blood pressure condition, often including signs of damage to the kidneys or liver.

The highest risk came with preeclampsia, a 40% higher risk, according to the study. This risk has been talked about for a long time – see Preeclampsia and Migraines.

It is, however, important to keep these numbers in perspective. Just how high is the risk?

From this study alone, this is what the risk of preeclampsia looks like:

Preeclampsia Risk with and without migraine

So note this. This “healthy” group includes people with migraine and without. So yes, far more people with migraine had preeclampsia than people without migraine who had preeclampsia. But your risk is still relatively low. And it’s a much better picture when it comes to hypertension and preterm delivery.

So what can you do? Actually, there are a number of things you can do to lower your risk even further, and keep your baby and yourself safe. For example:

  • Lower your risk for high blood pressure in other ways. Talk to your doctor about the medications you’re taking. Aim for a healthy lifestyle overall, which will include exercise, plenty of water, a healthy diet, and avoiding alcohol, smoking, and certain drugs.
  • Consider magnesium, which is a treatment for both migraine and preeclampsia. Read more at Preeclampsia, Migraine, and Magnesium
  • Other supplements and medications may help, such as calcium and vitamin D. Talk to your doctor about these. (Note that for migraine you won’t want to take calcium at the same time of day as magnesium.)
  • Talk to your doctor about your medical history.
  • Talk to your doctor about any changed in headache or related symptoms. This is very important.
  • Take a look at the Migraine During and After Pregnancy chart to know what you might expect during various stages.
  • Don’t ignore migraine symptoms overall – talk to a specialist about the many, many treatments that are available.
  • Check out The Myth-Busting Guide to Migraines and Pregnancy

Remember, although there seems to be some connection between migraine and some pregnancy risks, this study does not come anywhere close to telling us what the connection is. Yes, the researchers did adjust for some common risk factors to try to weed out weak connections. But we don’t know if there is some other common root cause, or if migraine symptoms may increase risk, or even if there is an unknown lifestyle connection.

The bottom line – it’s important to be aware of potential risks. But in most cases, these risks are small and manageable and no reason to avoid pregnancy.

This press release is only a preview of a report that will be given in April at the American Academy of Neurology’s 74th Annual Meeting. For more on the study, see Is migraine tied to complications in pregnancy?

Is Nitrogen Dioxide in Your Home Giving You a Headache?

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Nitrogen dioxide is a naturally occurring gas which in high quantities becomes a pollutant – and it might be giving you a headache.

Gas stoves - a source of nitrogen dioxide

Nitrogen dioxide, or NO2, may be produced from burning wood, and even lightening strikes. In small quantities, it’s not a concern – but in larger quantities in a small area, it becomes a pollutant. But more to the point, busy traffic can produce a lot of it, and even a fireplace or a gas stove in your home might be a culprit.

A recent study presented at the American Academy of Neurology annual meeting investigated the link between NO2 and migraine attacks in particular. They found that as NO2 in the air increased, so did migraine attacks. There was also an increase in people heading to urgent care or the emergency department because of a migraine attack.

Fine particle matter pollutants were also related to migraine urgent care visits.

(Read the study here: Air pollution, methane super-emitters, and oil and gas wells in Northern California: the relationship with migraine headache prevalence and exacerbation)

Trapping a lot of NO2 in a small space is a problem, and many of us spend a lot of time in a small space, such as a home or office. That means that we need to be thinking about ventilation, and sources of NO2 and other pollutants.

Traffic is a common issue, so if you live near a busy street, levels may already be high. What you can control is the idling of your own car in the garage.

Another issue is cigarette smoke, so any way that can be cut back will be a help.

More common issues would be things that “burn” – in particular, gas or wood stoves and fireplaces. These don’t have to be a problem if they are in good repair and properly ventilated. You might want to consider a hood over the stove, especially if you can’t open windows while you cook.

Opening doors and windows can be a help, but so can an air purifier with an activated carbon filter. Even these vary quite a bit, so you’re not going to want to simply rely on an inexpensive filter if you have a lot of NO2 in your house (for example, if you live by the highway with a smoker!). But they can help with both NO2 and other polluting particles that might increase your changes of migraine attacks.

Interestingly, lightening can indeed make a significant difference, depending on where you are. Check out Lightning’s ‘NOx-ious’ Impact On Pollution, Climate, and more migraine-specific Lightning and Migraine: More than just a Flash of Light and Asthma, Lightning, and Migraine (podcast). Also see Nitrogen Dioxide from the American Lung Association.

Which Medications are most recommended for Children and Teens with Migraine?

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These specific recommendations come from the American Academy of Neurology and the American Headache Society. A helpful summary was published at Practical Pain Management.

Children and migraine

As with many such studies, the recommendations come from the level of “confidence” that we have based on the results of clinical trials. For example, as we’ll see under “preventatives”, amitriptyline (Elavil) is “high confidence” as a preventative, but propranolol (Inderol) is “low confidence”. That doesn’t necessarily mean that amitriptyline is amazing and the best or that propranolol is useless. It does mean that our data for propranolol is a lot more limited – although so far it looks quite promising.

Before even getting to medication, the article (Ask the PharmD: What are the recommendations for preventing and treating pediatric migraine?) quite rightly points to lifestyle changes. We could add to that other treatments, including biofeedback and certain supplements. It’s tempting to look at the most recommended medications and think that these are the most recommended treatments – that’s not the case. With children, as with adults, there are some excellent treatments that you’ll probably want to try before any regular medications (especially preventative medications).

So let’s start with abortive medications – which drugs are most recommended to stop a migraine attack once it’s started? Remember, this is different with every child, but at this point the most recommended include triptans – but not any triptan. Most recommended are zolmitriptan, and then sumitriptan. Also the combination of sumitriptan and naproxen. However, these are only recommended for ages 12 and up (many medications simply haven’t been adequately studied in younger children).

Ibuprofen is also recommended, and is the #1 choice for younger children (6 months and older).

Sumitriptan/noproxen and zolmitriptan were also recommended for the related symptoms of photophobia and phonophobia – that is, sensitivity to light and noise.

If the symptoms are serious and frequent, and other medications haven’t worked sufficiently, preventatives may be tried.

For preventatives, as mentioned earlier, amitriptyline was the “high confidence” choice, with topiramate sneaking in under “moderate confidence”. These were only listed for ages 10-17.

Remember, preventatives should be far down the list of things to try. Steady doses of medication and their side effects are not to be rushed into. Check this article for other reasons to be less than optimistic about preventatives for children: New Study Questions Preventative Migraine Drugs for Kids

Remember, these recommendations do not automatically mean that they’re the best choice for you or your child. If other medication has been tried but these have not, it’s probably a good place to start. But it will be worth the trouble to investigate other non-drug treatments, many of which have been very helpful for children and teens.

For more details, take a look at the article at Practical Pain Management, especially the last section.

Concussion and Post-concussion Syndrome – Helpful Videos

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The American Academy of Neurology has some new and little known videos that are very helpful summaries of concussion and post-concussion syndrome. Made from a medical field perspective, they will also be helpful for anyone trying to understand the treatment of concussion today.

Neurobytes - Concussion videos

Concussion (a type of traumatic brain injury), because of its frequent connection to sport, is a highly controversial and often political issue. But whatever your personal point of view, it’s important to understand the terms that are being used today to even talk about the issue. The first video gives an overview of terms and the current understanding of the condition.

The second video gives a very brief overview of current treatment guidelines. A lot of of understanding of concussion has changed significantly in the last few years, as our understanding of the brain has improved, so you may be surprised by some of the recommendations.

One caution that might be needed – when we talk about a “gradual return to activities”, that may include 1-2 days of complete rest. That’s a component that is often missing from concussion treatment. When we talk about complete rest, that means no video games, no homework – very limited physical and mental activities. After that, a very gradual return to normal activities, with careful supervision, as you’ll see in the video below.

For more detailed recommendations, check out Coaches, Parents: Know the Sports Related Concussion Global Recommendations.



Botox recommended for Chronic Migraine, says American Academy of Neurology

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The American Academy of Neurology has officially come out in support of Botox, or onabotulinumtoxinA, as a treatment for chronic migraine.

In last week’s print edition of the journal Neurology, new guidelines were released for the use of Botox for chronic migraine, and certain other conditions. The strongest evidence was for Botox as way to increase the number of “headche-free” days for patients with chronic migraine. But there was also moderate evidence that it could improve overall quality of life, as affected by the headaches from chronic migraine.

Practice Guideline Update Summary on BotoxOn the other hand, the AAN is not recommending Botox for tension-type headache (even it it’s chronic) or for episodic migraine.

In other words, if you’re considering Botox, make sure you’ve been diagnosed with migraine, and that you have at least 15 days a month with a migraine attack.

These recommendations are not suggesting that Botox is the first treatment to try or the best treatment for chronic migraine. However, it is another treatment that’s worth trying to decrease headache days.

If you’re thinking of trying Botox, be sure to check out How to be Safe with Botox (10 tips).

Here’s the summary sheet of the updated Botox guidelines from the AAN (pdf).

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