Is There An Upper Age Limit For Use Of Botox For Chronic Migraine?

No, according to a new study as well as extensive clinical experience. The group of patients over 65 years old had the same benefit and no more adverse effects than the group aged 18 to 65. Botox in fact may be especially helpful after age 65 in that reduced frequency of headaches leads to reduced use of triptans, a class a medication that has risk of cardiovascular complications in patients who have undiagnosed coronary artery disease. Age is an important risk factor for cardiovascular disorders.

Jack Florin, MD
Neurologist

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Don’t Get Divorced If You Have Multiple Sclerosis

Multiple Sclerosis marriage
Marriage and Multiple Sclerosis

Social support is protective in many diseases, including cancer, in which married patients had a longer mean survival time than those who were single. The same holds true in multiple sclerosis. Patients living alone had higher disability scores, took a longer time to complete the 25-foot timed walk, a good test of motor function. The social support provided by a partner also leads to increased compliance with medication and psychological well-being. Males living alone had worse levels of disability than females living alone. Studies have shown that women usually have larger social networks and may thus need less caregiver support than men.

Jack Florin, MD
Neurologist

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New And Pipeline Parkinson’s Drugs

Since 1968 when levodopa was approved by the FDA to treat Parkinson’s, more effective drugs have been developed. Levodopa is now available in a combination product termed carbidopa-levodopa. There are other formulations which are only marginally better. Motor fluctuations are common with longstanding Parkinson’s, and patients will cycle suddenly from being “on” to “off.” Levodopa has a short half-life in the bloodstream and is inconsistently absorbed depending on the amount of protein in the stomach.

Two new options have recently become available. One is termed Rytary, which is a capsule with immediate and extended release beads of levodopa and carbidopa. It seems to have a longer duration of action and reduces off time. The other is more effective though more difficult to use. It is termed Duopa and is a gel suspension of carbidopa and levodopa, which is infused directly into the intestine through a feeding tube, also called a PEG-J tube. It requires a minor surgical procedure and a pump to infuse the medication. Risks and complications were mainly infection at the site of the tube and various intestinal complications. Excessive dosing may cause dyskinesias, which are involuntary movements.

In the pipeline is liquid levodopa, which is designed to be delivered subcutaneously through a belt pump system similar to an insulin pump. It would not be available before 2018, if at all. There are 2 new pipeline rescue drugs. For years, apomorphine (Apokyn) has been available, given by subcutaneous injection for an off period, but a caregiver is needed to give the injection, and low blood pressure with standing, nausea, and vomiting can occur. There is now a sublingual (meaning under the tongue) thin film strip of apomorphine, which is effective in 10 minutes and lasts 90 minutes and has less side effects. It may be available as early as 2016. Finally, there is a device similar to an asthma inhaler that delivers levodopa as a powder. This starts to work in 10 minutes and lasts 60 minutes. It may also be available in 2016.

Jack Florin, MD
Neurologist

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Misconceptions About Pregnancy Common Among Multiple Sclerosis Patients

Pregnancy and multiple sclerosis
Misconceptions About Pregnancy and MS Patients

Almost all MS patients go into remissions during pregnancy. Relapse rate, however, is high in the first 90 days after delivery. In the course of a woman’s life, the number of pregnancies does not adversely influence the course of MS and in fact, one study showed that the risk of MS is less among women with more pregnancies. Also, fertility and is no different among patients with MS. Lastly, most disease-modifying treatments are “category C” in pregnancy, which means that there are not enough studies to be sure that there are no adverse effects on the fetus. Patients generally have a low awareness of the need for birth control while on these medications.

Jack Florin, MD
Neurologist

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Can You Drive If You Have Multiple Sclerosis?

Fullerton, Neurology, Headache, Treatment, Center
Headache and Multiple Sclerosis

Most states, including California, list these diseases as a requirement for physician report to the DMV. Multiple sclerosis is not in that category, but patients with disability may have risk increased driving.

Many occupational therapy centers offer driver’s evaluation. Unfortunately, health plans and Medicare do not cover this evaluation, and costs are usually $400 to $500. A new study shows that physicians are usually accurate in their appraisal of their patients’ driving capabilities.

Jack Florin, MD
Neurologist

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How To Treat Hypnic Headache

headache treatment
Hypnic or “Alarm Clock” Headache.

This is also called “alarm clock” headache in that it wakes patients out of sleep, usually at a consistent time each night. A new report shows that the average age of headache onset is 62 years and that 8 out of 10 patients were women. About 60% also had migraine. In two-thirds of patients, the headache was bilateral, severe in intensity, and sharp in quality. Taking caffeine at bedtime as well as at the time of awakening led to a complete response in about 30% of patients and a moderate response in another 30%. Lithium, used most commonly in bipolar illness, led to a complete response in 70% and a moderate response in 20%. Lithium seems to work for other disorders such as cluster headache, which often awakens patients from sleep and is cyclical, varying with the seasons and with the circadian sleep cycle. About a third of patients also noted that physical activity / exercising immediately upon awakening with the headache reduced the intensity.
For more informaton on headache types visit www.headachegenius.com

Jack Florin, MD
Neurologist

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Should We Be More Aggressive In Treating MS?

The short answer is yes, if we can identify patients at high risk early in their course. A new study provides more evidence that early and effective treatment of MS matters and helps with this decision. This was a 2-year study of over 1700 patients with relapsing-remitting MS from 163 neurology practices in Germany. About 400 of the 1700 patients had at least 1 relapse in the first year, and they were considered to be the active group. The others were considered to be inactive. Within 2 years, the active group continued to have more relapses and had worsening of disability compared to the inactive group. They also had reduced work productivity, more absence from work, were likely to stop working, and had lower quality of life. Even those who continued to work reported their productivity was less.

Thus, patients who show “activity” on their current treatment should be changed to a different medication.

This study, by Stefan Vormfelde, MD, PhD, was presented at the 2015 Annual Meeting of the American Academy of Neurology. It is titled the PEARL study.

Jack Florin, MD
Neurologist

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Should MS Patients Stop Taking Their Medication?

MS patients often ask me when they can safely discontinue their disease-modifying treatment. This is mainly prompted by the fact that they have been stable for years. Very few studies are available to help with this decision. Now a new study identified 182 patients who were 40 or older and had been stable without increased disability or relapses for at least 5 years. These patients stopped their medications for various reasons, including lack of improvement, perceived disease progression, side effects, inconvenience.

Over the next 4 years, 1 in 4 patients had a relapse, about 1 in 3 had increased disability, and 1 in 10 had both a relapse and worsening disability.

Forty percent of these patients restarted their medication, and those who did had a 60% decrease in the rate of disability progression compared with those who did not.

This study, by Ilya Kister, MD, was presented at the 67th Annual Meeting of the American Academy of Neurology.

Jack Florin, MD
Neurologist

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Opioids For Chronic Pain?

This issue was debated at the 2015 Annual Meeting of the American Academy of Neurology. Clearly, it is an important issue. Chronic pain affects 100 million adults in the United States; overdose deaths from prescription painkillers increased 4 times over 10 years; there are more than 140,000 deaths, hundreds of thousands of overdose admissions; and there are millions of people addicted and / or dependent upon opioids. So-called “opioid use disorder” is seen in about 30% of people on chronic opioids.

These are frightening statistics. What should neurologists do when faced with patients who suffer from intractable pain? There is no consensus, but my personal view is that a case can be made for using opioids to treat “neuropathic pain” such as from painful diabetic neuropathy or lumbar radiculopathies (sciatica) but not for headaches.

Jack Florin, MD
Neurologist

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Can A Sense Of Purpose In Life Reduce Risk Of Stroke?

Purpose in life involves having meaning and being goal-directed. It changes little over time and may be a personality trait, which is not modifiable. Many studies have shown that positive psychological factors such as having a purpose in life are important in health outcomes. A new study shows that a 1-point increase in the score of a rating scale for “purpose in life” reduced the odds of having stroke by about 50%.

The reason is not clear. Possibly, these people had healthier lifestyles. It is important to understand what can motivate you, and in older adults, this may include volunteering, learning new skills, or being part of a community.

See Stroke, 2015, Volume 46, page 1071-1076.

Jack Florin, MD
Neurologist

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