Surgery for Migraine? Keep your scalp on!

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An excerpt from the Boston Globe April 2012

Debra Haining lay in a hospital bed at Massachusetts General Hospital, awaiting surgery. Both eyelids were colored purple, and blue dots were drawn on her forehead, including one on each temple, and one above her left eye.

The dots indicated the location where she feels the migraine, the trigger points, where the pain strikes. She is 57 years old and says that she never had a headache until five years ago, when she woke up feeling as if she’d been shot through the head.

She was forced to spend nearly every day in bed with the curtains drawn. She could not tolerate light, smell, or sound. Typically she rose only to see her 12-year-old son off to school in the morning and in the afternoon when he returned. Until recently, she had an ice pack to her head and could not drive a car.

A half-dozen medications, four different pain clinics, a variety of headache cocktails and injections, and numerous neurologists didn’t provide relief. Haining, who lives in Pawtucket, R.I., searched the Internet until she found Dr. W.G. (Jay) Austen Jr., of plastic and reconstructive surgery at Massachusetts General Hospital.

Haining says she was tired of doctors who suggested that she learn to accept a lifetime of pain, pills, and shots, and was relieved to find a doctor who offered to treat the cause of the migraine and not just the symptoms. “When you are debilitated and life comes to a halt, you are willing to try what’s out there.’’

In the operating room at Mass. General, Austen began surgery on Haining by making an incision in one of her eyelids in what would appear to be a routine blepharoplasty, a cosmetic surgery known as an “eyelid lift.”

Haining would benefit cosmetically by removal of this globular flat that settles into each eyelid with age. But the point, Austen says, is that this particular procedure provides “easy access” to the critical sensory nerves around her eyes that he believes were causing migraine pain.

This was just one of the three trigger points that Haining identified prior to surgery, and as he operated, Austen would be seeking a structural reason for that pain, a nerve compressed or impinged by surrounding bone or soft tissue.

This surgical approach was developed 12 years ago by Dr. Bahman Guyuron, chairman of the plastic surgery department at University Hospitals Case Medical Center in Cleveland, after several of his plastic surgery patients reported that their migraines improved after a cosmetic procedure known as a forehead lift.

A study published in the journal Plastic and Reconstructive Surgery in 2009 — led by Guyuron and submitted by Case Western Reserve University, the American Migraine Center, and the Center for Headache and Pain, Cleveland Clinic — found that just under 85 percent of patients who underwent the nerve decompression surgery reported at least a 50 percent reduction in migraine, calculating pain, frequency, and duration. Nearly 60 percent (28 of 49 patients) reported a complete elimination of pain. This compared with only 1 of 26 patients who had a sham surgery, in which the surgery was limited to exposure of the nerve but muscle and attachments were left intact. Reported side effects included forehead numbness, temporary hair loss and itching, a slight hollowing of the temple, and small change in eyebrow movement.

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Sound too good to be true?

Dr. Paul Mathew, neurologist at Harvard Medical School and fellow graduate of the 2014 AAN Palatucci Advocacy Leadership Program says yes….

In his recently published review on the subject, Dr Mathew explains that these surgeries are unproven, risky, expensive ($10,000-15,000) and are often not covered by medical insurance.  “Many patients have no or temporary benefits from the surgery and still wind up on long term narcotics”, he says,  and furthermore “These procedures have made their way into mainstream medicine without adequate investigation”.  This is why he has decided to make this subject the focus of his future advocacy efforts.

Click here to read the paper.

Click here to find out more about migraine.

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Petadolex for Migraine Prophylaxis: The Facts

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Posted by Sonia Jasuja, MSIV Drexel University College of Medicine

As a current student of traditional Western Medicine, I have been trained to turn towards modern pharmacology and away from natural remedies, for the most part.  However, as someone who has suffered from severe skin allergies all my life, I know how desperate patients can get in order to find something that really works! When Western Medicine fails us, where can we turn?

During my clinical Neurology rotation at Monmouth Medical Center, I saw another issue that plagues patients: Migraine.  While there have been great advances in the prevention and treatment of migraine, some patients are still left with debilitating pain. It was during this rotation that I first heard about Petadolex, or Petasites hybridus (aka Butterbur).

What is it? Butterber is an herbal plant that has been used for medicinal purposes, including migraine and headache, allergies, asthma, and many more. Most herbal remedies use the root extract in the form of a pill. It has properties that relieve spasms and decrease inflammation.1

Is it safe? Yes- studies have determined that Petasites is safe to use for the prophylaxis of migraine. The dose that was cited to have moderate efficacy is 150mg daily.2

Side effects are very mild and include burping, stomach upset, diarrhea, fatigue and itching.3

One important thing to keep in mind- make sure to only buy Petasites hybridus that is certified and labeled, “PA free”. “PA” stands for pyrrolizidine alkaloids, which cause adverse effects in the liver, lungs and circulatory system. PA’s can cause cancer.3

You should not take Petasites if you are pregnant or breast-feeding, have liver disease, or if you are allergic to ragweed, marigolds, daisies or other related herbs. 3

Does it work? Probably, but we still need more information! In 2006, Agosti et al. published “Effectiveness of Petasites hybridus preparations in the prophylaxis of migraine: A systematic review”. Of the two studies that were looked at, the systematic review showed that there is only moderate evidence for the effectiveness of Petasites at the dose of 150mg/day for a period of 3-4 months. The review also thoughtfully pointed out that confounding factors still need to be accounted for. These factors would include things like which migraine treatments have been successful or unsuccessful in the past, and any use of addictive or hormonal substances, such as nicotine or estrogens.2

The review article states that the overall effect size of the 150mg extract dose is approximately 15% percent lower migraine frequency rate per month compared to placebo.2

The bottom line.  If you have frequent or debilitating headaches, you should see you doctor for an evaluation.  You may need some diagnostic testing, and there are probably some very effective conventional medications you can try.  However, if you are still having frequent headaches despite that, Petasites might be worth a try.

REFERENCES

1. Brind’Amour, Katie. “Migraine Herbal Home Remedies From Around the World.”Healthlines RSS News. Healtline Editorial Team, 16 Apr. 2013. Web. 16 Nov. 2013.

2. R. Agosti, R.K. Duke, J.E. Chrubasik, S. Chrubasik, Effectiveness of Petasites hybridus preparations in the prophylaxis of migraine: A systematic review, Phytomedicine, Volume 13, Issues 9–10, 24 November 2006, Pages 743-746, ISSN 0944-7113, http://dx.doi.org/10.1016/j.phymed.2006.02.008.

3. “Butterbur Information | Evidenced-Based Supplement Guide.” MedicineNet. MedicineNet.com, n.d. Web. 16 Nov. 2013.

Foreign Accent Syndrome – Their “Problem” or Yours?

FAS3

Foreign accent syndrome (FAS) is a rare condition which causes affected patients to suddenly speak their native language in a foreign accent.

Cases of FAS were reported as early as 1900.  However, one of the best known historical cases is “Astrid L”, a Norwegian woman who suffered a traumatic brain injury from shrapnel during a WW2 air raid in 1941.  She survived, but found herself mispronouncing vowels in such a way that she seemed to have a German accent, leading to social isolation and stigmatization for the remainder of the war.

Since then, there have been about another 60 FAS cases reported in the literature and media, mostly in patients who have suffered acute neurologic events such as strokes, multiple sclerosis and head injury.

Unlike most neurologic syndromes, FAS has not been localized to a lesion in a particular brain area.

The only thing that can be said is that most affected patients have lesions affecting the dominant hemisphere in or around known language areas.

FLS

Brain imaging studies from a FAS patient: The MRI (left) shows enlargement of the Sylvian fissure from atrophy of the left temporal lobe. The PET scan (right) shows focal hypometabolism in the left temporal lobe.

Many affected patients were initially mute, then developed FAS as they recovered from a non-fluent aphasia:

There are also some cases of FAS that have developed after minor neurologic events, or even without any clearly identifiable neurological cause at all.  Some of these patients have had normal brain imaging, suggesting that the problem can be functional or psychogenic.

This is all further complicated by the fact that different listeners can perceive different accents in a single speaker.

The video clip is a patent with FAS syndrome after brain injury from hemiplegic migraine.  She is said to have a Chinese accent.  Does it sound Chinese or just slurred to you?

The table below is from a FAS case report, where the affected patient’s “foreign accent” was obviously described very differently by observers.

FAS2

This suggests that FAS may not be a true syndrome after all, but simply a listener-bound epiphenomenon.

What does this mean?

Well, we have already explained that most FAS patients have some kind of speech or language problem that changed how they speak.  That explains the association with lesions in the dominant hemisphere.   However the “foreign accent” may actually just something perceived by the listener – the variability of perceived accents is explained by the fact that listeners have different experiences with languages other than their own.

In other words FAS may not be a true syndrome, but simply an epiphenomenon that exists only in the ears of the beholder.

Headache pills, are they hurting more than they are helping?

Headache

Headache is a common problem.  Almost 20% of men and 40% of women in the USA experience recurrent headaches.  Headache is the most common reason for a neurology office visit, the third most common cause of missed work, and the seventh most common reason for a primary health care visit.

Headaches are  broadly divided into two categories:  Primary headaches, such as migraine and tension headache, are most common.  Secondary headaches are symptoms caused by other diseases, some of them serious like a ruptured aneurysm, brain tumors, acute glaucoma or vasculitis.

Most headache sufferers are using abortive medication as needed every time they experience the symptom:

Some are taking prescription medications such as triptans or drugs containing butalbital (such as Fioricet (c) or Esgic (c)).

Many more are using over the counter medications such as acetaminophen, ibuprofen or combination pills such as aspirin/acetaminophen/caffeine (Excedrin (c)).

This strategy can work, particularly for infrequent headaches, such as once or twice a week.

cdh

However, more frequent use of these medications, particularly short-acting triptans (such as sumatriptan) and drugs containing caffeine and butalbital, can lead to rebound headache, which leads to more medication use and more headaches, culminating in chronic daily headache from transformed migraine.

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The only way to deal with this is to temporarily stop the offending abortive drug and  start a daily preventative drug.  This will lead to short period of drug withdrawal, when the headaches may get worse before they ultimately get better.  This can sometimes necessitate short term headache infusions with dihydroergotamine (DHE) or a course of steroids.

Any headache sufferer who finds themselves in this situation should consult with a neurologist or other headache specialist.

Alice in Wonderland Syndrome

Caused by a disturbance of perception rather than an actual physiological change
Altered body image (Ex: big buildings look same size as person’s own body)
Distorted perception of size (micropsia, macropsia)
Distorted perception of the shape of objects
Loss of spatial perspective (sense of time and space)
Auditory or tactile hallucinations

AIWS generally affects a younger population and has several associated conditions. Migraine is the classic disease linked to AIWS, the distorted sensations can either begin before a migraine (aura or “warning”) or afterwards, and in younger patients can even occur without headache

Check out these first-hand accounts of people with this interesting phenomenon:
Size Matters: Living in a Lewis Carroll ‘Wonderland’ – ABC News

When the world looks like a real-life Wonderland

Experience: I have Alice In Wonderland syndrome 

A Not So Pleasant Fairy Tale: Investigating Alice in Wonderland Syndrome | Serendip Studio

Other causes of Alice in Wonderland Syndrome are:
psychoactive drugs
infectious mononucleosis
malignancy
temporal lobe epilepsy

Certain tests & imaging studies help rule out secondary causes:
urine toxicology screen
monospot test   
(for mononucleosis)
MRI brain
with and without contrast (to look for malignancy)
EEG   
(to detect seizures or seizure-like activity)

Sounds scary, right? Well, good news is it’s not as bad as it sounds. Most patients who experience AIWS as children will outgrow the condition as adults. Patients should be monitored for worsening of symptom severity and frequency. If all studies are negative and the patient continues to improve clinically, then further evaluation and/or treatment is not needed. Best management for future attacks is focused on migraine prophylaxis and lifestyle modifications (healthy diet, regular exercise, adequate sleep).

Posted By Sidra Ghafoor, Drexel University College of Medicine Class of 2013