Treatment Of Migraine With Aura As Opposed To Without Aura

Migraine is the most common neurological disorder, affecting more than 80 million people in the US and in Europe and is certainly the most disabling. About a third of migraine patients have attacks with aura. A new study has shown that migraine attacks with aura are less responsive to sumatriptan (Imitrex) than migraine without aura. On the other hand, use of an inhaled DHE preparation seems effective in both migraine with and without aura. That drug will likely be approved by the FDA within the next year. It is not clear whether migraine with aura is merely more difficult to treat with sumatriptan or that there are different mechanisms that result in different responses to therapy. Understanding these differential responses to therapy may be an important step to personalized medicine in acute migraine treatment.

See Neurology, May 5, 2015, for articles beginning on page 1880 and a second article beginning on page 1828.

Jack Florin, MD
Neurologist

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Stem Cell Clinics for MS and ALS?

Not on your life. This is a mushrooming business, almost entirely unregulated and, in the opinion of most experts, quackery. These are run by physicians with no formal background or expertise in stem cell research, claiming to treat more than 30 diseases, including ALS, multiple sclerosis, lupus, erectile dysfunction. Many of these clinics also do “stem cell facelifts.” As you might have guessed, this is not covered by health insurance, and fees are high. There are reports of deaths, and no research has shown that the treatments work.

There is a place for stem cell therapy in multiple sclerosis. This is done at a few university-based multiple sclerosis centers. Patients’ stem cells are “harvested” from their bloodstream, then grown in cell culture. In the meantime, the patient is treated with multiple immunosuppressive medications, and the stem cells are then reinfused. This treatment holds promise.

Jack Florin, MD
Neurologist

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What Causes Alzheimer’s – Tau or Amyloid?

Why has a decade with untold millions of dollars in research based on the amyloid hypothesis of Alzheimer’s yielded no clinical benefit for patients? One possible answer is that by the time amyloid is seen on PET scans, medications that are able to clear it from the brain do not improve brain function. Two new studies also weigh in on this question.

One autopsy study of a large number of Alzheimer’s disease patients concluded that the primary cause of cognitive decline and memory loss was more likely accumulation of tau (neurofibrillary tangles) than amyloid plaques.

The second concluded that declines in memory and hippocampal volume occur earlier than findings of abnormal amyloid on PET scans. Memory and hippocampal volume, the hippocampus being a critical area of the brain in memory, worsen continuously from age 30 before abnormal amyloid PET appears. The lead author concludes that these declines are a fundamental characteristic of typical aging.

Intensive research into the cause of Alzheimer’s continues, but the target may be changing.

See: (1) Brain, March 23, 2015; (2) JAMA Neurology, March 16, 2015.

Jack Florin, MD
Neurologist

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Should Behavioral Approaches Be First-Line Treatment For Alzheimer’s?

According to a study published March 2, 2015, in the British Medical Journal, a third of dementia patients in nursing homes and about 15% of dementia patients outside nursing homes were prescribed an antipsychotic. These medications carry a “black box” warning by the FDA, and their use has been shown to increase mortality.

Antipsychotics are given to treat symptoms of irritability, agitation, depression, anxiety, sleep disorders, aggression, apathy, delusions. An alternative approach is to identify the situations that trigger these problem behaviors. This takes more time. Caregivers should be educated, meaningful activities for the patient can be helpful, and simplifying tasks and establishing structured routines can also help. Interventions include de-cluttering the environment, using music or simple activities to help engage the patient, and using a calm voice instead of being confrontational. Caregivers should also get breaks from their responsibilities to avoid burnout and taking their frustration out on patients.

Jack Florin, MD
Neurologist

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Can A New Amyloid PET Scan Diagnose Alzheimer’s Accurately?

It can, with high sensitivity but not high specificity. The reason for the low specificity is that at least 25% of cognitively normal older adults and almost 50% of people older than 80 show beta-amyloid on PET scans. All of them do not progress to symptomatic Alzheimer’s. The scan, however, is very helpful to distinguish Alzheimer’s from other causes of dementia. It is commercially available but is not reimbursed by Medicare.

Jack Florin, MD
Neurologist

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Migraine in Children

Children with migraine often come up against barriers, the most important being their parents. Children have a right not to suffer when treatment is available, but frequently, parents are resistant to have their child use prescribed medication. Children further tend to downplay the impact of the pain on their lives and families.

Migraine is common in childhood and adolescence. Before puberty, boys are affected more commonly than girls.

The same medications used in adults, mainly triptans, are appropriate. Maxalt and Axert are FDA approved for children and teens, but all triptans work and are well tolerated. Preventatives can include the supplement butterbur or prescribed medications similar to those used in adults with migraine. Evidence supports use of Depakote, Topamax, beta-blockers. Depakote is reasonable in children and young teens. It comes in sprinkles for those who cannot swallow pills. Topamax is a good choice for obese teens with caution that higher doses may cause cognitive symptoms. Cyproheptadine has been used for years by pediatricians with little supporting evidence.

We are a Children’s Headache Center, recognized by the National Headache Foundation.

Jack Florin, MD
Neurologist

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What Does POTS Have To Do With Migraine?

First of all, what is POTS? It stands for postural orthostatic tachycardia syndrome. More than 500,000 people in the US may have POTS. It affects women 5 times more often than men and is usually diagnosed in the early teens or 20s. It is thought to be caused by a virus that damages or triggers an autoimmune attack on the part of the nervous system that maintains orthostatic tolerance.

These patients have lightheadedness or fainting with standing. They are diagnosed by heart rate increasing by at least 30 beats per minute and being greater than 120 beats per minute within 10 minutes of standing as compared to heart rate with the patient seated or supine.

Now, a new study concluded that 28% of people with POTS have migraine, whereas the prevalence of migraine is 18% in the general population. Further, 46% of migraineurs have a lifetime risk of syncope (fainting). Why this is so is not known.

Treatment is to increase salt and fluid intake, to exercise regularly, and certain medications may help. Prognosis varies. Some patients have symptoms for many years. For more information, see Neurology Reviews, April 2015.

Jack Florin, MD
Neurologist

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