What the Gut Can Teach Us About Migraine.

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What the Gut Can Teach Us About Migraine.

Nice recent summary of what we know about interactions between the head-brain and the gut-brain in migraine. Touches on why dietary changes help some migraineurs.

Take home paragraph:

The physiological connection between the gut and the brain as well as the influence on brain function and behavior has been well established. Inflammation at the level of the trigeminovascular system is hypothesized to play a role in migraine pathophysiology and could be influenced by inflam- mation and immune modulation in the GI tract and systemi- cally as evidenced by recent studies [90, 91]. Likewise, there is evidence to suggest that the gut microbiota plays an impor- tant role in the brain-gut axis and aberrancies may be associ- ated with neurological disease like migraine

Some interesting details:

81 % of migraineurs reported dyspepsia compared to 38 % of healthy controls.

…

The ANS [Autonomic Nervous System] is implicated in the generation of migraine and GI dysfunction with evidence for overlapping symptoms in both domains such as nausea, vomiting, dyspepsia, IBS, and gastric stasis. The ANS may also be the link between alterations in brain function and behavior secondary to intestinal flora dysbiosis.

…

Gastric stasis has long been implicated in association with
migraine. Early experimental studies by Volans et al. reported a delay in effervescent aspirin absorption in 19 out of 42 migraineurs during an attack, but not during the headache- free period and not found replicated in patients with tension- type headache [53, 54]. More recent studies suggest delayed gastric emptying occurs during spontaneous migraine attacks, visually induced migraines, and during the headache-free interictal period

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Although neurobiology offers a biological explanation for migraine, this explanatory framework may have less power to legitimate migraine if it is understood in terms that replicate already existing assumptions about men and women in pain.

stakeholders’ best attempts to legitimate migraine are undermined by cultural meanings of headache and migraine that are overlaid with assumptions about gender. These gender assumptions overdetermine how medical knowledge about headache disorders is produced, disseminated, and used.

Joanna Kempner in Not Tonight

Lady pain isn’t real pain.

Botox is woefully underused in the treatment of chronic migraines

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nyheadache:

The FDA approved Botox injections for the treatment of chronic migraine headaches more than five years ago. I just discovered that in this period of time only 100,000 chronic migraine sufferers received this treatment. According to the Migraine Research Foundation, 14 million Americans suffer from chronic migraines, so less than 1% of them have received this potentially life-changing treatment.

There are several possible explanations.
1. Botox is expensive and many insurance companies make it difficult for patients to get it. They require that the patient first try 2 or 3 preventive drugs, such as a blood pressure medicine, (propranolol, atenolol, etc.), an epilepsy drug (gabapentin, Depakote, Topamax), or an antidepressant (amitriptyline, nortriptyline, Cymbalta). Patients also have to have 15 or more headache days (not all of them have to be migraines) in each of the three preceding months. If these requirements are met, the doctor has to submit a request for prior authorization. Once this prior authorization is granted, the insurer will usually send Botox to the doctor’s office. After the procedure is done, the doctor has to submit a bill to get paid for administering Botox. This bill does not always automatically get paid, even if a prior authorization was properly obtained. The insurer can ask for a copy of office notes that show that the procedure was indeed performed. All this obviously serves as a deterrent for many doctors. Some of them find that the amount of paperwork is so great and that the payment is so low and uncertain, that they actually lose money doing it.

2. There are not enough doctors trained in administering Botox. This is becoming less of a problem as more and more neurologists join large groups or hospitals where at least one of the neurologists is trained to give Botox and gets patients referred to him or her. However, doctors in solo practices or small groups without a trained injector can be reluctant to refer their patients out for the fear of losing a patient. They may suggest that this treatment is not really that effective or that it can cause serious side effects.
The majority of doctors who inject Botox are neurologists, but there are only 15,000 neurologists in the US and many specialize in the treatment of strokes, Alzheimer’s, epilepsy, MS, and other conditions. This leaves only a couple of thousand who treat headache patients. Considering that there are 14 million chronic migraine sufferers, primary care doctors will hopefully begin to provide this service.

3. Chronic migraine patients are underdiagnosed. Many patients will tell the doctor that they have 2 migraines a week and will not mention that they also have a mild headache every day. The mild headaches they can live with and sometimes my patients will even call them “normal headaches”, which they don’t think are worth mentioning. Good history taking on the part of the doctor solves this problem. However, once doctors join a large group or a hospital, they are pressured to see more patients in shorter periods of time, making it difficult to obtain a thorough history.

4. Some patients are afraid of Botox because it is a poison. In fact, by weight it is the deadliest poison known to man. However, it is safer than Tylenol (acetaminophen) because it all depends on the amount and too much of almost any drug can kill you. Fifty 500 mg tablets of Tylenol kills most people by causing irreversible liver damage. Hundreds of people die every year because of an accidental Tylenol poisoning, while it is extremely rare for someone to die from Botox. Tens of millions of people have been exposed to Botox since its introduction in 1989. It is mostly young children who have gotten into trouble from Botox because the dose was not properly calculated. Kids get Botox injected into their leg muscles for spasticity due to cerebral palsy, although children with chronic migraines also receive it (the youngest child with chronic migraines I treated with Botox was 8).

In summary, if you have headaches on more than half of the days (not necessarily all migraines) and you’ve tried two or three preventive drugs (and exercise, meditation, magnesium, CoQ10, etc), try to find a doctor who will give you Botox injections. Botox is more effective and safer than preventive medications because it does not affect your liver, kidneys, brain, or any other organ.

http://www.nyheadache.com/blog/botox-is-woefully-underused-in-the-treatment-of-chronic-migraines/

In British Columbia, PharmaCare will not cover Botox injections for migraines. With injection fees, costs are about $1000 every 3 months.

It’s possible to get your secondary insurance to partially cover Botox, but they usually require you to ask PharmaCare every year before they’ll cover it. This involves getting your neurologist to spend time during your precious appointments to write a letter asking for a special authorization and then a few hours of additional paperwork and bureaucracy wrangling. Every year. Probably costs more in time than it would to cover the damn drug.

To did

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Today I

  • canceled my breakfast plans
  • worked hard on not vomiting for 2 hours
  • made my bed
  • made eggs and toast
  • responded to responses to my ad for a cleaner because I’m too sick to clean my own damn house
  • emailed my psychologist to quit therapy because I keep missing appointments because I’m so sick
  • contacted several clinics that do therapy over the internet because my GP gets antsy when I don’t have a therapist ever since topamax made me suicidal (oops!) and because my friends can only handle so much whining about migraines
  • set up meetings to get the right people to sign forms to extend my medical leave
  • lay on the couch and read tumblr
  • heated up leftovers for lunch
  • looked at my goals sheet and tried to figure out a way to work 4 hours this week
  • got back in bed

Level 3 pain

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Pain scales don’t do a great job describing functionality. My head hardly hurts today, but I’m so weak I can’t sit up straight and I have to prop my phone on a pillow.

I can type a little something, but since everything is moving I can’t make sense of rows of data or graphs or my code.

I’m thrilled to not be in agony, but I still can’t work. And that is pretty frustrating.

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Not Tonight examines how migraine can simultaneously disrupt so many lives and continue to be questioned and trivialized by the culture at large. Why do some kinds of pain generate deep sympathy and hefty economic investment, while other kinds are ignored? Why do we privilege and even praise some sorts of pain, while others are perceived as unimportant? Why does some people’s pain matter more than others? Why, for example, are endurance athletes who suffer for their successes celebrated as heroes (even as they choose and train for such pain), while people who live in chronic pain (also a feat of endurance, and one for which there is no finish line) are dismissed as “whiny” or weak willed? Sometimes, a particularly severe headache attracts attention (and sympathy) as a symptom of something more serious, like an aneurysm or a stroke. But much of the time, migraine is seen as a “silly excuse.” That the medical recasting of migraine as a neurobiological disorder has not altered this cultural configuration highlights the social contests that surround migraine’s legitimacy and
cultural significance.

Joanna Kempner in Not Tonight

Not Tonight is SO GOOD. I’m probably going to quote half the book on here by the time I’m done with it. If you have migraine, especially chronic migraine, I highly recommend getting a copy.