Green Light Reduces Migraine Headache

By Pat Anson, Editor

Many people who suffer from migraines will tell you that bright light can trigger a horrible headache.

But researchers at Beth Israel Deaconess Medical Center in Boston have found that a narrow band of green light can significantly reduce light sensitivity – known as photophobia – and reduce headache severity in migraine sufferers.

"Although photophobia is not usually as incapacitating as headache pain itself, the inability to endure light can be disabling," said Rami Burstein, PhD, Vice Chair of Research in the Department of Anesthesia, Critical Care and Pain Medicine and Academic Director of the Comprehensive Headache Center at Beth Israel Deaconess, as well as the John Hedley-Whyte Professor of Anaesthesia at Harvard Medical School.

"More than 80 percent of migraine attacks are associated with and exacerbated by light sensitivity, leading many migraine sufferers to seek the comfort of darkness and isolate themselves from work, family and everyday activities."

Five years ago, Burstein and his colleagues made the surprising discovery that blue light hurts migraine patients who are blind. The finding prompted research that found photophobia could be alleviated by blocking blue light. However, because that study involved only blind patients, who cannot detect all colors of light, researchers devised a way to study the effects of different colors of light on headache in patients who are not visually impaired.

In the first study of its kind, published in the journal Brain, Burstein and colleagues found that a narrow band of green light worsens migraine significantly less than other colors of light, and that low intensities of green light can even reduce headache pain.

The researchers asked 43 patients experiencing acute migraine attacks to report any change in headache when exposed to different intensities of blue, green, amber and red light.

As the intensity of the light increased every 30 seconds, patients were asked if their headache intensified. Nearly 80 percent of patients said their migraines got worse when exposed to white, blue or amber light, while green light was found to reduce pain in 20 percent of patients.

Researchers then measured the magnitude of the electrical signals generated by the retina (in the eye) and the cortex (in the brain) of patients in response to each color of light. They found that blue and red lights generated the largest signals in both the retina and the cortex, and that green light generated the smallest signals.

Researchers also used laboratory rats to study neurons in the thalamus, an area of the brain that transmits information about light from the eye to the cortex. These neurons were found to be most responsive to blue light and least responsive to green light, explaining why the migraine brain responds favorably to green light.

"These findings offer real hope to patients with migraines and a promising path forward for researchers and clinicians," said Burstein.

Burstein is now working to develop a more affordable light bulb that emits "pure" (narrow band wavelength) green light at low intensity, as well as affordable sunglasses that block all but this narrow band of pure green light. Currently, the cost of one such light bulb is prohibitively high ($360 to $500, according to this research) and the technology to block all but pure green light in sunglasses is also very costly.

Light therapy – also known as infrared or laser therapy – is also being used to treat pain from aching joints, muscles and low back pain. Red and green light are also used as a treatment for skin disorders such as acne, aging spots and wrinkles. The theory is that light therapy increases circulation and stimulates the growth of collagen in skin.

About a billion people worldwide suffer from headaches caused by migraines, which affect three times as many women as men.

Migraine affects about 36 million adults in the United States, according to the American Migraine Foundation. In addition to headache pain and nausea, migraine can cause vomiting, blurriness or visual disturbances, and sensitivity to light and sound. About half of people living with migraine are undiagnosed.

What Does a Migraine Look Like?

By Pat Anson, Editor

Sometimes there’s an aura. Or bright lights. Or blurred vision.

About a billion people worldwide suffer from headaches caused by migraines, which affect three times as many women as men. Most non-sufferers understand the headache part, but explaining what a migraine looks like isn’t easy – which is why the makers of Excedrin invented a simulator to help people better understand  migraines and the impact they can have.

"Migraines are more than bad headaches – the pulsing pain can be debilitating, and the associated symptoms like nausea and extreme sensitivity to light and sound, really impact people's lives," said Dr. Elizabeth Seng, a New York based psychologist.

GSK Consumer Healthcare brought together several migraine sufferers and had them explain the symptoms they most often experience during a migraine episode, including aura, sensitivity to light and blurred vision. The symptoms were then replicated with the simulator and conducted in a controlled environment from everyday life – like riding the subway or going to a restaurant -- to give non-sufferers the chance to safely experience the full range of migraine symptoms

Many found the experience unsettling and nauseating, as you’ll see in this short video that Excedrin recently began airing on TV and over the Internet:

Excedrin partnered with Andy Cohen, a best-selling author, TV personality, producer and migraine sufferer, to help spread awareness about the impact migraines can have on relationships with friends, spouses and co-workers. He hopes the simulator will help non-sufferers better understand the migraine experience.

"Growing up with migraines, I experienced firsthand how debilitating an episode can be and how much it can affect relationships with loved ones," said Cohen. "In my experience, both personal and professional, I've seen how migraines can become a third party in relationships – creating tension in, sometimes, already murky waters."

Migraine affects about 36 million adults in the United States, according to the American Migraine Foundation. In addition to headache pain and nausea, migraine can cause vomiting, blurriness or visual disturbances, and sensitivity to light and sound. About half of people living with migraine are undiagnosed.

A Migraine Sufferer Finds Hope Again

By Paul Hannah, Guest Columnist

On a Sunday morning 33 years ago, I was reading a newspaper in bed and was suddenly struck with a headache. I hadn't really had many headaches before, so I expected that this would pass with some non-prescription medication and an hour or so in bed.

I was very wrong.

I still have that headache today. If it would have stayed at a 1/10 pain level, I probably would not have done much about it. However, it didn't stay that low and that was where the problem lies.

When the headache moves to 4/10 or 5/10 I get concerned, because if I don't stop it at that point, it will rapidly scale up to a full migraine.

I have read other accounts of migraines, but very few accord with mine. My neck gets stiff, the trapezius muscles lock up, and my eyes start to hurt. I become rapidly photophobic and the pain gathers and localizes in the frontal lobe of my brain.

Once it reaches 6/10, I get a syringe from my migraine drawer and inject Maxolon into my arm muscle and immediately lie down. As a result of the photophobia, I have built myself a four poster bed so that I can draw the curtains and be in total darkness. After the Maxolon kicks in, I drink some liquids, often very strong coffee, and take as many of the various painkillers as I dare.

PAUL HANNAH

About fifty percent of the time, that is enough and spending the next five or ten hours in bed gets me well enough to function again. The other fifty percent of the time, it gets worse. Much worse.

It feels like someone is reaching into my skull and squeezing the frontal lobe of my brain with each beat of my heart. At this point, it becomes imperative, as bizarre as it seems, for me to concentrate. This is because the pain momentarily stops when I sub-consciously hold my breath, and then when I do finally breathe, it gets worse.

These migraines happen so frequently and unpredictably that I have given up traveling. I joke and say that I have seen the inside of too many foreign hospitals - but it is no joke, I love traveling. I miss it terribly.

I have a sympathetic doctor who will write scripts for pethidine (Demerol) every six weeks. It took literally years of doctor shopping to find him. If I have any pethidine left, I give myself an injection. The wave of relief that passes through me with that drug is hard to describe. I heard an opium addict describe her relief like this: "The pain is still there, you can still feel its presence, but it doesn't hurt anymore." It is like that for me.

Every migraine sufferer I have discussed this with has resonated with three annoying things that people come up with. Some women (and it always has been women in my experience) place two fingers to their temples and say, "I have a migraine". Anyone that has ever experienced a 10/10 could no more speak and function as 'normally' as that, than fly. They simply have no idea how bad it is. Fingers are regarded as among the most sensitive to pain areas of the body and anyone hitting a thumb with a hammer can attest.

Eighteen months ago I had an accident in my workshop and cut off my left index finger, half of my thumb and mashed up the other fingers in that hand. The pain level was 5/10. I took the painkillers the paramedics offered, but I didn't need them. The painkillers I took in hospital were for my head, not my hand.

The second annoying thing is when we are asked, "Have you looked into the cause?" I am barely able to contain my sarcasm when confronted with this. I desperately want to say something like "Well goodness me! That IS a good idea, why didn't I think of this thirty years ago?" But I don't, I just look away and say something equally inane.

Just as annoying are those that have an aunt who was cured by giving up coffee (tried it for 9 months, no change), going through menopause (strangely enough, not all that helpful to me) or taken some homeopathic/natural or equally nonsense cure (One said a foot massage was sure to fix it).

I am fortunate in that I live in Australia, a place where universal free healthcare is considered a citizen's right and a government's responsibility. So I have had several MRIs, X-rays and even an EEG, nothing has ever shown up as anything but normal.

When Francis Collins finished the Human Genome Project I thought it was marvelous from a human achievement point of view, but nothing more. I had no idea that it was going to change my life. But change it, it did and in all the right ways.

When I heard about this from another genuine migraine sufferer I took a blood test and for the first time in 33 years I had a non-normal result. It seems there is a genetic mutation called MTHFR, and if a person has one of them, it makes it difficult to process vitamin B. I have two of the sods.

I have spent my life being deficient in Vitamin B2, all the while my blood was full of the stuff. Both of those conditions can cause migraines. For the last eight weeks I have been taking a number of supplments and a cream - DHEA/CHYSIN, zinc, B-2, 5-MTHF and D-3. So far, I have had nothing worse than a 4/10 headache and I have every reason to suspect that this improvement will continue.

The Human Genome Project has given me something I thought I would never have again: hope. And hope to the hopeless is a marvelous thing. Truly marvelous.

I urge every migraine sufferer who can afford it to take the test. This isn't foot massage or acupuncture nonsense, it might actually work.

Paul Hannah lives in a small town just north of Brisbane, Australia on a few acres of bush populated with wallabies, koalas and a wide variety of native birds. He is retired and enjoys writing, history, astronomy and woodwork. 

Pain News Network invites other readers to share their stories with us.  Send them to:  editor@PainNewsNetwork.org. 

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Childhood Emotional Abuse Raises Risk of Migraine

By Pat Anson, Editor

New research is adding to the growing body of evidence linking child abuse with migraines. In a large survey of young adults, nearly two-thirds who suffer from migraines said they experienced emotional abuse as children.

"Emotional abuse showed the strongest link to increased risk of migraine," said Gretchen Tietjen, MD, University of Toledo. “Childhood abuse can have long-lasting effects on health and well-being."

In the study, nearly 14,500 people aged 24 to 32 were asked the question: "How often did a parent or other adult caregiver say things that really hurt your feelings or made you feel like you were not wanted or loved?"

Of those diagnosed with migraines, 61% said they had been abused as a child. Of those who never had a migraine, 49% said they were abused.

The participants were then asked whether they had experienced emotional, physical or sexual abuse as children. Physical abuse was defined as being hit with a fist, kicked, or thrown down on the floor, into a wall, or down stairs. Sexual abuse included forced sexual touching or sexual relations.

Nearly half of the participants answered yes to emotional abuse, 18% said they were physically abused, and 5% sexually abused.

Those who were emotionally abused were 52% more likely to have migraine than those who were not abused. But those who were sexually or physically abused were not significantly more likely to have migraine.

“Multiple studies have shown a strong link between childhood trauma and subsequent risk for developing chronic pain in adulthood, for instance, fibromyalgia. This study appears to be showing a similar association in migraine,” said Beth Darnall, PhD, Clinical Associate Professor at Stanford University and co-chair of the Pain Psychology Task Force at the American Academy of Pain Medicine. 

“The collective findings suggest that childhood emotional trauma has a lasting impact on emotional and sensory experience throughout life, and underscore trauma as an important therapeutic target to reduce chronic pain and its impact, and to possibly prevent chronic pain.”

A similar study published last year found that children who witnessed domestic violence between their parents were significantly more likely to experience migraine headaches as adults.

Researchers at the University of Toronto surveyed over 12,000 women and 10,000 men who participated in the 2012 Canadian Community Health Survey-Mental Health. Participants were asked if they experienced physical abuse, sexual abuse or if they witnessed parental domestic violence as children.

"We found the more types of violence the individual had been exposed to during their childhood, the greater the odds of migraine. For those who reported all three types of adversities -- parental domestic violence, childhood physical and sexual abuse -- the odds of migraine were a little over three times higher for men and just under three times higher for women" said Sarah Brennenstuhl, PhD, first author of the study.

Previous research has also shown the risk of depression and suicide ideation is about twice as high for migraine sufferers. People with migraine under the age of 30 have six times the odds of depression compared to migraineurs aged 65 and over.

Migraine is thought to affect a billion people worldwide and 36 million adults in the United States, according to the American Migraine Foundation. It affects three times as many women as men. In addition to headache pain and nausea, migraine can also cause vomiting, blurriness or visual disturbances, and sensitivity to light and sound.

FDA Approves New Inhaler for Migraine

By Pat Anson, Editor

The U.S. Food and Drug Administration has approved a new type of inhaler for the treatment of acute migraine in adult patients with or without aura.

Onzetra Xsail delivers a low dose of a dry powder formulation of sumatriptan, the most commonly prescribed medication for migraine.

"Onzetra Xsail provides a new and much needed treatment option for what can be a debilitating condition for millions of people," said Roger Cady, MD, director of the Headache Care Center and associate executive chairman of the National Headache Foundation.

"The Xsail Breath Powered Delivery Device allows the medication to be deposited deep into the nose, an area that is rich with blood vessels. By delivering the medication here, Onzetra Xsail provides targeted and efficient delivery with the potential for fast, consistent relief, while also limiting the amount of medicine that goes down the back of the throat."

The inhaler is activated when a user exhales into the device, automatically closing the soft palate and sealing off the nasal cavity. Through a sealing nosepiece placed into the nostril, the exhaled breath carries medication from the device directly into one side of the nose. The medication is dispersed deep into the nasal cavity, reaching areas where it can be rapidly absorbed.

As the medication is delivered, the air flows around to the opposite side of the nasal cavity and exits through the other nostril. Closure of the soft palate helps prevent swallowing and reduces gastrointestinal absorption.

Migraine is thought to affect a billion people worldwide and about 36 million adults in the United States, according to the American Migraine Foundation. It affects three times as many women as men. In addition to headache pain and nausea, migraine can also cause vomiting, blurriness or visual disturbances, and sensitivity to light and sound. About half of people living with migraine are undiagnosed.

“While there are many acute migraine treatment options available, more than 70% of patients are not fully satisfied with their current migraine treatment. Given this high dissatisfaction, there remains an unmet need to provide patients with fast-acting, well tolerated therapies that deliver consistent relief,” said Stewart Tepper, MD, professor of neurology at the Geisel School of Medicine at Dartmouth.

The FDA approved Onzetra after clinical trials showed the inhaler provided headache relief to about 40% of users within 30 minutes. About two-thirds of users reported pain relief after two hours. Side effects include abnormal product taste, nasal discomfort, rhinorrhea and rhinitis.

Medical Marijuana May Reduce Migraine Headaches

By Pat Anson, Editor

New research is adding to the growing body of evidence that medical marijuana can be used to treat migraine headaches.

In a small study of 121 migraine patients by researchers at the Skaggs School of Pharmacy and Pharmaceutical Sciences at the University of Colorado, 103 patients reported a significant decrease in the number of migraine headaches they had every month. The frequency of headaches dropped from an average of 10.4 to 4.6 per month. Most patients used more than one form of marijuana and used it daily. The study was published in the journal Pharmacotherapy.

"There was a substantial improvement for patients in their ability to function and feel better," said senior author Professor Laura Borgelt, PharmD. "Like any drug, marijuana has potential benefits and potential risks. It's important for people to be aware that using medical marijuana can also have adverse effects."

Fifteen of the patients reported marijuana use had no impact on their headaches, while three said they had more headaches.

The study looked at patients treated at Gedde Whole Health, a private medical practice in Colorado that utilizes medical marijuana for a variety of conditions. Inhaled marijuana appeared to be the favorite method for treating acute migraines, while edible cannabis, which takes longer to be absorbed into the body, helped prevent headaches.

Exactly how cannabis relieves migraines is not fully understood. Natural cannabinoid receptors in the brain, connective tissues, and the immune system appear to have anti-inflammatory and pain-relieving properties. These cannabinoids also seem to affect neurotransmitters like serotonin and dopamine.

"We believe serotonin plays a role in migraine headaches, but we are still working to discover the exact role of cannabinoids in this condition," Borgelt said.

“We have had numerous patients finding results with migraines and the use of cannabis,” said Ellen Lenox Smith, a Pain News Network columnist who is a caregiver to medical marijuana patients in Rhode Island.

“We just had a woman out at the house a few days ago that was suffering will full body Reflex Sympathetic Dystrophy (RSD) and when she took one hit on a vaporizer of day meds, you could actually see the forehead relax and had headache relief immediately. When it is right for you, the results are amazing.” 

A 2013 study on rodents published in The Journal of Neuroscience found that triptans – a drug widely prescribed to treat migraine – appear to activate cannabinoid receptors just as marijuana does.

A 2007 study published in the European Journal of Critical Pharmacology found that migraine patients possessed significantly lower levels of endogenous cannabinoids than healthy control subjects.

Imaging Identified as Most Wasteful Medical Test

By Pat Anson, Editor

Should you get an MRI for your headache?

What about a CT scan for low back pain?

Or a bone-density scan for someone under the age of 65?

In most cases, the answer to all of those questions is no, according to the Choosing Wisely campaign of the ABIM Foundation, which seeks to reduce the use of hundreds of unnecessary and costly medical tests. Experts say an MRI or CT scan of the lower back can cost over $1,200 and does nothing to relieve your back pain.

Since Choosing Wisely was launched in 2012, over 370 wasteful procedures have been identified by over 70 medical societies, such as the American Academy of Sleep Medicine and the American Academy of Neurological Surgeons. Each organization was asked to identify an initial list of five medical services that may be unnecessary. Many societies went far beyond that, returning with two or even three lists.

A neurologist at the University of Michigan says the list of recommendations from the American Academy of Neurology (AAN) only scratches the surface. Brian Callaghan, MD, has identified 74 tests and procedures related to neurology that are often unnecessary. Many involve the use of imaging.

“The two biggest areas that might be done more than they should are imaging for low back pain and imaging for headaches,” Callaghan said. “It’s a big problem and it costs a lot of money – we’re talking a billion dollars a year on just headache imaging.”

According to a recent study at the University of Michigan, one in eight visits to a doctor for a headache or migraine end up with the patient going for a brain scan. Often a doctor will order a CT or MRI scan to ease a patient’s fear that they may have a brain tumor or some other serious issue causing their pain. Physicians could also order a scan to protect themselves legally in case of a future lawsuit.

In most cases, however, the brain scan will be useless. Previous research found that only 1 to 3 percent of brain scans of patients with repeated headaches identify a cancerous growth or aneurysm that's causing the problem. Many of the issues that a scan might identify don’t pose a serious threat or may not require treatment right away. There is also the risk of a false positive that could generate unnecessary fear and alarm.

“These are all areas where lots of physicians agree that you’re more likely to get harmed by doing the procedures,” said Callaghan, whose study was recently published in the journal Neurology.

Callaghan isn’t encouraging you to say no if your doctor wants to image your brain or lower back, but he hopes his research will inspire a thoughtful discussion between doctors and patients about the purpose of the test and its value

“Ordering an MRI for a headache is very quick, and it actually takes longer to describe to the patient why that’s not the best route,” Callaghan said. “These guidelines are meant for physicians and patients both, to trigger a conversation.”

Besides imaging, another treatment that is widely questioned is the use of opioid pain medication to treat headaches and migraine. The Choosing Wisely campaign recommends that opioids only be used as a last resort for severe headaches, including migraine. Overuse of any pain reliever – even over-the-counter medications -- are known to make headaches worse.

My Life with Migraines

By Sara Batchelder, Guest Columnist

I have had migraine disease since I was 22. My first migraine was in 1992, the year I graduated from college. 

I am now 45, and my migraines have become chronic and daily.  I have lost two jobs, many friendships, my social life, and my relationship of eleven years.  This year, I also lost my ability to work full-time at a regular job.  The only reason I can still work part-time is that my ex employs me and allows me to work whenever I am able.  Thank goodness for that. Working gives me a purpose and makes me feel like a productive member of society.  It is an extreme struggle to work twenty hours a week though. 

I also have thyroid disease (my thyroid gland was removed when I was 29), celiac disease (I have been 100% gluten free for a year), depression, anxiety, infertility, and extreme allergies to many things, such as food, pollen, dust, cats, you name it. 

I now have a multi-pronged approach to my treatment.  For migraine, I have botox injections every three months, I see a “natural MD” for various treatments, and I take Relpax (a triptan) and opioids (Norco and morphine). 

I am still learning a lot about celiac disease, but I stay ever vigilant that I do not ingest any gluten whatsoever, even one molecule.  It’s a learning experience and constantly challenging.  For instance, I will visit a restaurant that I consider safe, get “glutened” and cross that restaurant off the list.  I am down to four restaurants that I can eat at. 

Since I am too sick to cook for myself most of the time, I graze on various packaged food - some good, some not so good.  I eat protein bars when traveling, although I do not travel often anymore.  It’s a lot of work to make sure all the food I eat is gluten-free and free of all of my other food allergies. 

sara met with sen. barbara boxer while advocating for migraine research

I’ve been dealing with allergies for all of my 45 years.  My “natural MD” (my voodoo doctor, as I jokingly call him) gives me small doses of LDA shots, which are helping a bit.  He also believes that I have a lyme-like disease called Bartonella, which he is treating me for.  I am on so many vitamins that I won’t even go there. I take Wellbutrin for depression, nothing for anxiety, and since I am now 45, the infertility has played itself out. 

Deep breath. That’s a lot of illness and treatment.

Even with all of this, my scariest problem today is the government’s war on pain patients who take opioids.  After the DEA stormed one of my doctors’ offices in bulletproof vests with guns drawn (to request appointments with two doctors -- couldn't that have been done by phone?), all of my doctors, but one, have withdrawn ALL narcotic treatments for ALL migraineurs. 

It baffles me why this policy exists.  This is discrimination plain and simple.  I want to sue, but no lawyer will take the case.  I know that many addicts lie and tell doctors that they are migraine patients, since migraine is an invisible disease that cannot be diagnosed with blood tests, MRI’s, or anything else, but these are doctors whom I have a 10 year relationship with! 

They are either petrified of the DEA or always thought that I was an addict, and didn’t care enough to deal with that.  Either way, what the heck I am supposed to do?  Without my weekly pain shots, I can no longer work full-time.  If I still didn’t have one doctor on my side, I’m pretty sure I would have committed suicide. 

My private disability was denied due to some technicality.  SSI pays less than I can make part-time and SSI doesn’t allow the disabled to work part-time anyway (don’t get me started on that). 

I am very, very fortunate to work in California, where I have been on part-time disability.  But it will only last for one year, so I will be on my own again soon anyway.  I don’t know about other people, but there is no way I can survive in California on half-pay.  I was barely making ends meet while working full-time.  Now that I am single again, I cannot rely on someone else to support me. It is terrifying!!!

I have met and will soon meet again with members of Congress to discuss more funding for migraine and headache research through an organization called Headache on the Hill. That organization does not support opioid treatment for migraine at this time, but I still want to address the opioid issue with other pain patients.  Who will join me?
 

Sara Batchelder lives in California, where she received an MBA with honors from the University of San Francisco and works as a controller for small architecture firm. Sara volunteers at her local credit union and tries to advocate for migraineurs as much as she can.

Pain News Network invites other readers to share their stories with us. 

Send them to:  editor@PainNewsNetwork.org.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Study Finds Doctors Order Too Many Imaging Tests

By Pat Anson, Editor

Doctors are still ordering too many imaging tests for low back pain and headache, according to an early study of the effectiveness of the Choosing Wisely campaign, a national effort to reduce the number of unnecessary medical treatments and procedures.

In an analysis of seven clinical services with questionable benefit to patients, published in JAMA Internal Medicine, researchers found that the use of five procedures either increased or stayed the same; while there were only slight declines in the use of two others.

CT and MRI imaging tests for simple headache decreased from 14.9 percent to 13.4 percent, while cardiac imaging for patients with no history of heart problems dropped from 10.8 percent to 9.7 percent.

The prescribing of nonsteroidal anti-inflammatory drugs (NSAIDs) increased from 14.4% to 16.2% for hypertension, heart failure or chronic kidney disease. Testing for human papillomavirus (HPV) in young women also rose, from 4.8% to 6%.

Imaging tests for low back pain (53.7%), pre-operative chest x-rays (91.5%), and antibiotics for sinusitis (91.5%) remained stubbornly high.

The study was based on a database of insurance claims from 2013 for about 25 million members of Blue Cross and Blue Shield health plans.

“It remains an open question whether clinicians or consumers at large are aware of specific Choosing Wisely recommendations or have changed their attitude toward unnecessary tests and procedures,” wrote Ralph Gonzalez, MD, in a commentary published in JAMA Internal Medicine.

“In a fee-for services system, most delivery systems continue to get paid for tests and drugs. Payers are able to pass on these costs to employers and patients, creating a vicious cycle.”

The Choosing Wisely campaign was launched in 2012 by the ABIM Foundation (American Board of Internal Medicine) with the goal of reducing waste and unnecessary medical tests and treatments. It has grown to include a list of hundreds of frequently used procedures that have little value or may, in fact, be risky.

“Most people with lower-back pain feel better in about a month whether they get an imaging test or not. In fact, those tests can lead to additional procedures that complicate recovery,” Choosing Wisely states on its website.

“A study that looked at 1,800 people with back pain found that those who had imaging tests soon after reporting the problem fared no better and sometimes did worse than people who took simple steps like applying heat, staying active, and taking an OTC pain reliever. Another study found that back-pain sufferers who had an MRI in the first month were eight times more likely to have surgery, and had a five-fold increase in medical expenses.”

The Choosing Wisely campaign also discourages doctors from performing epidural steroid injections if a patient doesn’t show signs of improvement after one injection. A number of prominent pain doctors have told Pain News Network the shots are overused, with some patients getting dozens of injections.  

New Wearable Devices for Chronic Pain

By Pat Anson, Editor

With opioid pain medications becoming harder to get and many patients looking for safer alternatives with fewer side effects, a growing number of companies are offering wearable “electrotherapy” devices for pain relief.

There’s the Cefaly headband for migraines, ActiPatch for sore muscles, AcuKnee for osteoarthritis, and the Quell nerve stimulator, which is designed to treat a range of chronic pain conditions. All are part of a fast growing $2.8 billion market for wearable medical devices.

“There’s a big problem brewing on the horizon. And that is the pain medications are being removed from the market, slowly but surely,” says Phillip Muccio, President and founder of Axiobionics, which has been making customized electrotherapy devices for 20 years.

“Electrical stimulation has a way of reaching into the body and interacting and coordinating what happens to the body. That’s why it a fascinating area of medicine because not a lot of things will do that, especially non-invasively and non-pharmacologically.”

Most of the new devices use a form of electrical stimulation to block or mask pain signals – a technique developed decades ago known as Transcutaneous Electric Nerve Stimulation (TENS).

Unlike the old TENS units, which are typically used for about 30 minutes, wearable devices are designed to be worn for several hours at a time or even while sleeping.

image courtesy of axiobionics

“TENS is like a short acting opioid. It’s basically only effective when it’s on,” said Shai Gozani, MD, President and CEO of Neurometrix. “If you’re going to deal with chronic pain, you have to have a wearable, chronically usable device, because pain can be two hours a day or it could be 24 hours a day. TENS devices historically haven’t been designed at all for wear-ability or continuous use.”

Neurometrix recently introduced Quell, an electrotherapy device that Gozani compares to a spinal cord stimulator. But instead of being surgically implanted near the spine like a stimulator, Quell is worn externally on the upper calf below the knee.

image courtesy of neurometrix

“We really look at spinal cord stimulation as the model. We’re trying to make that available but in a non-invasive, wearable way -- versus TENS devices which are really intended for local muscle stimulation. We don’t stimulate the muscles, we stimulate the nerve alone,” Gozani told Pain News Network.

“The upper calf has a lot of nerves. It’s comfortable. It’s discrete. So it meets the requirement to have a large segment of nerves to stimulate, but it’s also highly usable from a wear-ability perspective.”

A small study recently conducted by Neurometrix found that over 80% of Quell users had a significant reduction in pain and two-thirds were able to reduce the amount of pain medication they were taking.  Participants in the study had several different types of of chronic pain, including fibromyalgia, sciatica, neuropathy and arthritis.

When it comes to clinical studies, medical device makers have a clear advantage over pharmaceutical companies, which often have to spend years and tens of millions of dollars proving the safety and effectiveness of their drugs before they’re approved by the Food and Drug Administration. Device makers are held to a lower regulatory standard.

“Devices are approved by FDA basically for safety and not necessarily for efficacy. It’s a lot easier to demonstrate that with a device than if you have to demonstrate a new drug. You basically run one study or two and show that nobody got electrocuted by a TENS unit and you’re good to go,” said Bob Twillman, PhD, Executive Director of the American Academy of Pain Management.

Device makers can even get fast track approval from the FDA without any clinical studies -- if they say a new device is substantially equivalent to an older device already on the market.  Quell, for example, was given clearance by the FDA because of its similarity to Sensus, another Neurometrix device that's worn below the knee for pain relief.

A significant disadvantage for device makers is that most are not covered by public or private health insurers – meaning patients have to pay for them out of pocket. Three years ago, Medicare stopped covering TENS for low back pain, saying the technology was “not reasonable and necessary.”

The lack of reimbursement also makes many doctors unwilling to prescribe wearable devices and unfamiliar with the technology behind them, which stifles innovation.  For that reason, Neurometrix took an unconventional path and made Quell available without a prescription – bypassing insurers and doctors so it could market directly to consumers for $249 a unit.

“We thought it was imperative to get it over the counter. We wanted to make sure it was accessible to patients," said Gozani. "Wear-ability changes everything. Wear-ability is the game changer in terms of optimizing pain relief. I think it's huge."

Blood Test Identifies Women Prone to Migraine

By Pat Anson, Editor

Researchers may have discovered a new marker for episodic migraine – lipids in the blood that regulate inflammation in the brain.

In a small study involving 88 women, researchers found that total levels of the lipids -- called ceramides or sphingolipids -- were significantly decreased in women with episodic migraine when compared to women without migraine. Episodic migraine is defined as less than 15 headaches per month. The women in this study had an average of 5.6 headache days a month.

"While more research is needed to confirm these initial findings, the possibility of discovering a new biomarker for migraine is exciting," said study author B. Lee Peterlin, DO, with the Johns Hopkins University School of Medicine. The study is published in Neurology,  the medical journal of the American Academy of Neurology.

Ceremides are bioactive lipids that may be involved in other neurological disorders, such as dementia and multiple sclerosis.

Women with migraine had approximately 6,000 nanograms per milliliter of ceramides in their blood; while women without headache had about 10,500 nanograms. Every standard deviation increase in total ceramide levels was associated with over a 92% lower risk of having migraine. Two other types of lipids, called sphingomyelin, were associated with a 2.5 times greater risk of migraine.

The researchers tested their theory by analyzing the blood of a random sample of 14 of the women. They were able to correctly identify those who had migraine and those who did not based on their lipid levels.

"This study is a very important contribution to our understanding of the underpinnings of migraine and may have wide-ranging effects in diagnosing and treating migraine if the results are replicated in further studies," said Karl Ekbom, MD, with the Karolinska Institute in Stockholm, Sweden, who wrote an accompanying editorial.

Ekbom noted there were limitations in the study. Only women were included, chronic migraine was not studiedm and an unusually high number of participants had migraine with aura

Migraine is thought to affect a billion people worldwide and about 36 million adults in the United States, according to the American Migraine Foundation. It affects three times as many women as men. In addition to headache pain and nausea, migraine can also cause vomiting, blurriness or visual disturbances, and sensitivity to light and sound.

Migraine Device Reduces Headache Pain

By Pat Anson, Editor

A device that looks like a space age tiara not only helps prevent migraine attacks, but also relieves headache pain once a migraine starts, according to the results of a small clinical trial.

In a study of 20 migraine sufferers, published in The Journal of Headache and Pain, the Cefaly device provided "statistically significant" pain relief, as well as an 81 percent reduction in the number of migraine attacks. Patients in the study also said they used less migraine medication.

Cefaly was approved last year by the U.S. Food and Drug Administration as the first transcutaneous electrical nerve stimulation device specifically authorized for use prior to the onset of migraine pain.  Previous studies of the device only focused on migraine prevention.

"This is great confirmation on what we thought about the high efficacy of Cefaly," said Dr. Pierre Rigaux, chief executive officer of Cefaly Technology, a company based in Belgium. "We knew Cefaly to be very safe and with minimal side effects, but now we learn that it's not just the frequency of migraine days that's reduced for every four out of five patients, but the intensity of pain during a migraine attack is reduced as well."

IMAGE COURTESY OF CEFALY TECHNOLOGY

The battery-powered device, which is worn over the forehead like a headband, uses tiny electrical impulses to stimulate the trigeminal nerve, which has been associated with migraine headaches. Cefaly requires a prescription and costs about $349. The device is only available through the company’s website and is not covered by insurance. It’s been available in Europe and Canada for several years.

It was on a trip to Canada that Maria Coder learned about Cefaly and – at the urging of her boyfriend Jay– reluctantly agreed to buy one.

“At the time my boyfriend and I got into a big fight because he wanted me to use it right away and I didn’t really like the idea. I’d never heard of it and I was nervous about using it,” said Coder, who has suffered from migraine for nearly two decades.  

The device sat in its box for about a week before she finally tried it.

“I was alone in the apartment and put on the headband and loved it. I fell in love with it. I started to feel better, but I thought beginner’s luck,” Coder told Pain News Network. “I tried it a few more times and then it took on a life of its own. Now I feel like a wimp when I get a migraine because I don’t get them hardly ever compared to before. It’s down to maybe 3 to 5 a month, whereas for almost ten years it was chronic, almost daily.”

Coder, who works in public relations, wrote a letter to Cefaly Technology that eventually turned into a job as a publicist for the company. She also recently married her boyfriend – wearing the Cefaly device for her daily 20-minute session during a break after the ceremony and before her reception.

“I really love and I really believe in it. I didn’t believe in it at first, when I got it. And then the more that I used it, the more I couldn’t deny the results,” she said.

Migraine is thought to affect a billion people worldwide and about 36 million adults in the United States, according to the American Migraine Foundation. It affects three times as many women as men. In addition to headache pain and nausea, migraine can also cause vomiting, blurriness or visual disturbances, and sensitivity to light and sound.

maria coder

In 2013, the FDA approved the marketing of another device -- the first transcranial magnetic stimulation (TMS) device approved for the relief of migraine pain. The Cerena TMS is placed at the back of the head to release a pulse of magnetic energy to the brain’s occipital cortex, which may stop or lessen pain caused by migraine headaches.

Researchers Say Back to School Headaches Often Real

By Pat Anson, Editor

With summer nearly over and millions of children heading back to school, many parents will hear a familiar refrain:

“I’ve got a headache. Can I stay home from school?”

While parents may be tempted to think their child dreads going back to school and just wants to prolong summer a little longer, kids now have research to back them up.

In a study of emergency room visits by children, researchers at Nationwide Children’s Hospital in Columbus, Ohio found that pediatric headaches do indeed increase in the fall – often because children are stressed out by abrupt changes in their summer routines, nutrition and sleep patterns.

“When we saw many of our families and patients in clinic, the families would report that their child or teenager’s headaches would increase during the school year,” said lead researcher Ann Pakalnis, MD, a neurologist and Director of the Comprehensive Headache Clinic at Nationwide Children’s Hospital.

“So, we decided to go back and look at emergency department visits for that time period and see if there were more visits here at certain seasonal variations during the year.”

Pakalnis and her colleagues analyzed about 1,300 emergency room visits to the hospital by children from 2010 to 2014. The number of pediatric headaches was stable throughout the year, except for the fall – when headaches in school aged children surged by nearly a third.

"We see a lot of headaches in young boys, from five to nine years of age, and in boys they tend to get better in later adolescence,” said Pakalnis, who is also a professor of Clinical Pediatrics and Neurology at The Ohio State University College of Medicine. “In teenage girls, migraines oftentimes make their first presentation around the time of puberty and unfortunately tend to persist into adulthood.”

The two types of headaches seen most often by physicians are tension headaches and migraines. About 20 percent of all pediatric patients 11 years and older suffer from migraine, which are often associated with nausea and vomiting, as well as sensitivity to light, sound and smell. Tension headaches tend to feel more like a painful tightening around the head.

The increase in fall headaches may be attributed to a number of factors, including academic and social stress, schedule changes and an increase in extracurricular activity. Other common headache triggers include lack of sleep, too much caffeine, lack of exercise and too much time on a computer or mobile device.

Researchers say headaches can often be prevented, just by getting three meals a day, drinking enough liquids, and getting adequate sleep.

“Your brain is like your cell phone,” said Howard Jacobs, MD, a headache specialist at Nationwide Children’s. “If you don’t plug your cell phone in, it doesn’t have energy, it doesn’t work well. If you don’t plug your brain in by providing energy, it doesn’t work well and that causes headaches.”

If headaches persist or get worse, Jacobs says a doctor should be seen.

“A sudden, severe headache or a change in the headache sensation from previous, what we call ‘first or worst’ headaches should be evaluated,” said Jacobs. “Another good rule of thumb is that if the headaches are interfering with a child’s normal routine, then it is time to get them evaluated, so therapy can be instituted to return your child’s life to normal.”

Nationwide Children’s Hospital produced this video about the headache study:

Findings from Nationwide Children's Hospital physicians demonstrate that headaches increase in fall in children, a trend that may be due to back-to-school changes in stress, routines and sleep.

For tension headaches, doctors say over-the-counter pain relievers such as acetaminophen, ibuprofen or naproxen can be helpful, but they can make headaches worse if taken too often.

Until recently, treatment options have been limited for children with migraine.

In May, the U.S. Food and Drug Administration approved Treximet for pediatric migraine patients 12 years of age and older. Treximet is the first approved prescription drug for migraine to contain both sumatriptan and naproxen. Sumatriptan is a triptan that works in the brain by reducing vascular inflammation. Treximet was approved by the FDA for use by adults in 2008.

In June, the FDA also approved Zomig nasal spray for the treatment of migraine in pediatric patients 12 and older. Zomig provides pain relief in as little as 15 minutes, with most patients obtaining some relief in about two hours. Zomig was approved for use by adults in 2003.

Childhood Trauma Linked to Adult Migraine

By Pat Anson, Editor

Children who witness domestic violence between their parents are significantly more likely to experience migraine headaches as adults, according to a large new study published in the journal Headache.

Researchers at the University of Toronto examined a nationally representative sample of over 12,000 women and 10,000 men who participated in the 2012 Canadian Community Health Survey-Mental Health. About 6.5% of the men and 14.2% of the women experienced migraine, which is consistent with prior research.

Participants were asked if they had experienced three types of childhood trauma: physical abuse, sexual abuse or if they witnessed parental domestic violence.

"We found the more types of violence the individual had been exposed to during their childhood, the greater the odds of migraine. For those who reported all three types of adversities -- parental domestic violence, childhood physical and sexual abuse -- the odds of migraine were a little over three times higher for men and just under three times higher for women" said Sarah Brennenstuhl, PhD, first author of the study.

Researchers said the most surprising finding was the link between migraines and parental domestic violence. Even after accounting for variables such as age, race, and socioeconomic status, men and women who had witnessed parental domestic violence had 52% and 64% higher odds of migraine compared to those who did not see their parents fighting.

"The cross-sectional design of our study does not allow us to determine if the association between early adversities and migraines is causative, but our findings do underline the importance of future prospective studies investigating the long-term physical health of children exposed to parental domestic violence,” said co-author Esme Fuller-Thomson, professor and Sandra Rotman Endowed Chair at University of Toronto's Factor-Inwentash Faculty of Social Work.

Previous research by Fuller-Thomson has found that depression and thoughts of suicide are more likely among individuals with migraine.

The risk of depression and suicide ideation is about twice as high for those who experience migraine. Individuals with migraine who are under the age of 30 had six times the odds of depression compared to migraineurs aged 65 and over.

Migraine is thought to affect a billion people and about 36 million adults in the United States, according to the American Migraine Foundation. It affects three times as many women as men. In addition to headache pain and nausea, migraine can also cause vomiting, blurriness or visual disturbances, and sensitivity to light and sound. About half of people living with migraine are undiagnosed.

The month of June is Migraine Awareness Month.

Doctors Prescribing Opioids for Migraine Despite Risks

By Pat Anson, Editor

Physicians are still prescribing opioid painkillers or barbiturates to treat migraine, even though frequent use of the drugs can make headaches worse and raise the risk of addiction.

Over half the patients who visited a headache center in New York City said they had been prescribed opioids and/or barbiturates, according to a new study presented at the annual scientific meeting of the American Headache Society. About 20 percent of the 218 patients surveyed, most of whom had a migraine diagnosis, said they were still taking the drugs.

"Headache specialists are often in a difficult position when patients request opioids or increasing quantities of barbiturates," said lead author Mia Minen, MD, Director of Headache Services at NYU's Langone Medical Center. "Although many patients find these effective, they are known to contribute to headaches related to medication overuse."

Minen and her research team identified which physicians were prescribing the drugs and found the most frequent first prescribers of opioids were emergency room physicians, while general neurologists were the most frequent first prescribers of barbiturates. Primary care physicians were also identified as first prescribers.

"Taken as a whole, these data provide a useful snapshot of the wide variety of physician specialties that might benefit from additional education on the appropriate use of opioids and barbiturate-containing medications in patients with headaches," said Minen.

Opioids and barbiturates should only be used as a last resort to treat migraine, according to the American Board of Internal Medicine's "Choosing Wisely" campaign. The campaign recommends the first medications for migraine should be either over-the-counter pain relievers or a class of prescription drugs called triptans that are made specifically for migraine.

"This study underscores the fact that prescribers may not be aware of best practices in migraine care,” said Beth Darnall, PhD, a pain psychologist, clinical associate professor at Stanford University and author of Less Pain, Fewer Pills.

“Problems arise when ‘crisis solutions’ are applied as the de facto treatment for daily management of pain. Patients may believe that opioids are beneficial but they lead to worse migraine and headache pain, and are not considered appropriate first-line treatment for these conditions. If possible, patients should seek a specialized evaluation with a board certified specialist to ensure they receive medications that will help them in the long run.”

Darnall called opioids and benzodiazepines “a dangerous combination of medications,” and said they should be avoided or combined only under close medical supervision.

The problem extends far beyond the borders of the United States. According to the recently released Global Burden of Disease Study, the number of headaches caused by medication overuse has risen by 120% since 1990. Medication overuse headache is the 18th leading cause of disability worldwide.

New “Landmark” Class of Migraine Drugs Being Developed

Meanwhile, clinicians and researchers at the American Headache Society’s annual meeting are reportedly excited about a new class of drugs called Calcitonin Gene-Related Peptide (CGRP) monoclonal antibodies, which are showing promise in treating high-frequency episodic migraine and chronic migraine. Research studies on CGRP are being presented at the meeting, which draws more than 1,000 migraine specialists from around the world.

"This development is a transformative moment in migraine treatment," said Peter Goadsby, MD, who is chief of the UC San Francisco Headache Center and one of the world's leading headache treatment experts. "Up till now, migraine patients have had limited choices for preventive treatment. Now four pharmaceutical companies are showing positive results in human trials targeting CGRP mechanisms."

The new drugs appear to reduce elevated levels of the peptide known as calcitonin gene-related peptide, which is a key driver of migraine pain. Versions of anti-CGRP therapies are being tested by Alder Pharmaceuticals, Amgen, Eli Lilly and Teva Pharmaceuticals.

Teva reported that in a Phase II clinical study its CGRP therapy achieved a significant reduction in the number of headache hours after one week, with more than half of patients experiencing a 50% or greater reduction in headache frequency.

Amgen’s research showed showed that its anti-CGRP product also reduced the number of migraine days by 50% in about half the treated patients after 12 weeks.

"The potential of these new compounds is enormous and gives us real hope that effective specific treatments for migraine may be on the near horizon," said Goadsby. "The development of CGRP antibodies offers the simple, yet elegant and long awaited option for migraine patients to finally be treated with migraine preventives; it's a truly landmark development."

There has not been a new class of anti-migraine drugs since the development of triptans in the early 1990s.

Migraine is thought to affect a billion people and about 36 million adults in the United States, according to the American Migraine Foundation. It affects three times as many women as men. In addition to headache pain and nausea, migraine can also cause vomiting, blurriness or visual disturbances, and sensitivity to light and sound. About half of people living with migraine are undiagnosed.

The month of June is Migraine Awareness Month.