Do Supplements Help In Multiple Sclerosis?

Vitamin D has long been recognized to reduce risk of MS and probably to modify the course. New studies point to the importance of melatonin as well. It seems to modulate the effects of vitamin D. It would fit the recognized latitude effects of sunshine on MS susceptibility, often attributed to vitamin D, but melatonin levels also vary by latitude. It has antioxidant, anti-inflammatory, and immune regulation effects. It also helps mitochondrial function. Melatonin production is dependent on the availability of serotonin, and decreased melatonin is seen in MS, bipolar disorder, depression, and some forms of cancer. Some disease-modifying drugs used in MS increase melatonin levels, which fall when the treatments are stopped. The best dose for MS patients is not known. Studies are ongoing. Three milligrams at bedtime is commonly used to help sleep. New research shows that folate supplementation is also important. One milligram should be used. This is available by prescription only. Increased homocysteine levels occur in MS. They also increase the risk of cardiovascular disorders, often seen in MS patients, and high-dose folic acid may negate these unwanted effects.

Jack Florin, MD
Neurologist

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Is The Future Here For Neurostimulation For Headache?

Check the report in Neurology Reviews March 2015, which is a summary of presentations at the Eighth Annual Winter Conference of the Headache Cooperative of Pacific.

Cefaly is a transcutaneous supraorbital neurostimulator device, indicated in the United States for prevention of migraine. With a physician’s prescription, it can be purchased for around $300. It clips onto the forehead, is battery-powered, and delivers a series of electrical pulses and should be used 20 minutes a day. Almost 40% of patients had a reduction in migraine days per month of at least 50%. About half of the patients were dissatisfied, either because of lack of effect or uncomfortable paraesthesias from the stimulation. It may be increasingly effective with continuous use over months.

Transcranial magnetic stimulation has been approved by the FDA since May 2014 but is not available for general use yet. It has been tested as a preventative device and also to treat each headache. It seems to work only in patients who have migraine with aura. It is a handheld wand-like device and placed close to the skull and patients activate it with 2 pulses within 1 hour of the onset of the visual aura. Data are mostly but not consistently positive in clinical trials.

Vagal nerve stimulation is a new noninvasive technique for cluster headache. It is a device held over the vagal nerve in the left side of the neck. Stimulating that nerve has been shown to be effective in patients with intractable epilepsy. In that disorder, the device is implanted, but with cluster, it is noninvasive. It is designed to treat each attack, rather than as a preventative. One in 4 patients seems to respond and thus would not need injectable sumatriptan or oxygen. The device is approved in Europe and Canada, not in the US at this time.

Occipital nerve stimulation has been used for years. It is well established that occipital nerve blocks with local anesthetics can block cluster headaches, and these injections can be given every several days until the standard oral medications start to work. There is also an implantable occipital nerve stimulator that gives continuous pulses to the occipital nerves, presumably blocking their activation. This technique is unlikely to be widely used because there are problems with electrode migration, cable discomfort, muscle spasms, infection, battery depletion.

Deep brain stimulation consists of various techniques, targeted at different disorders, mainly Parkinson’s. It is also used to treat intractable cluster headaches, with stimulation targeted at the hypothalamus. It seems effective but should be considered a “last resort,” as there are significant risks, including cerebral hemorrhage and stroke.

Jack Florin, MD
Neurologist

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Is Epstein-Barr Virus The Antigen That Triggers Multiple Sclerosis?

The cause of multiple sclerosis remains elusive, but a preponderance of research indicates that it is a combination of a genetic predisposition and environmental factors. The most promising environmental factor is previous infection with Epstein-Barr virus. Acute infection with this virus in late childhood and early teens results in an infectious mononucleosis. Infection in early childhood is usually asymptomatic. The geographic distribution of MS, i.e., more common in temperate climates, which correlates with the developed world, could be the fact that Epstein-Barr infection occurs in late childhood or early teens in areas where hygiene is better. This would provoke a stronger immune response. Migrants from high-risk to low-risk areas carry the risk if they migrate after approximately the age of 15.

A study in Neurology, March 31, 2015, adds strength to this hypothesis. An Epstein-Barr antigen gene has been identified. MS risk is 5 times greater in people who have anexpression of the 1.2 allele, whereas it is 5 times less likely in those with the 1.3B allele. This finding reinforces the idea that Epstein-Barr virus contributes to disease development.

MS may thus resemble other immune-mediated diseases in which infectious agents are thought to have a key role. For example, strains of enterovirus by infecting pancreatic beta cells may trigger type 1 diabetes mellitus. A norovirus strain contributes to a type of Crohn’s disease seen in mice. Also certain genotypes are known to affect the clinical outcome and the response to therapy of patients with the hepatitis C virus.

It is likely that part of the genetic predisposition to MS is attributed to variants in genes that interact with the Epstein-Barr virus.

Jack Florin, MD
Neurologist

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Does Botox Work For Posttraumatic Headaches?

The most common posttraumatic headache has features of migraine rather than of tension-type headaches. Botox is the only treatment approved by the Food and Drug Administration for chronic migraine and is widely used. It has never been shown to be effective for tension-type headache. A fairly high percentage of patients following mild concussion develop posttraumatic headaches with features of migraine. They may be episodic or chronic.

According to a study published in the journal Headache in March 2015, sixty-four active duty service members who suffered mild traumatic brain injury developed intractable posttraumatic migraine. They were treated with Botox according to the approved chronic migraine injection protocol. Almost two-thirds improved. This percent is similar to the 70% improvement seen in chronic migraine groups.

Jack Florin, MD
Neurologist

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