Headlines September 2005

September 13th Meeting: Talk It Over Night—Learn From the Expert

The East Bay Headache Support Group is more than just a place to listen to informative guest speakers. We also like to get together at least once per year for an informal meeting, or Talk It Over Night. The theme of the evening will be “Learn from the Expert,” with discussion facilitated by Michael Stein, M.D., co-founder and medical advisor of the group.

Dr. Stein has a private neurology practice in Walnut Creek, and specializes in aiding headache patients to gain control over their symptoms. He is also the director of the Neurological Institute of the East Bay which conducts studies of drugs for headache treatment and prevention.

Celebrating Women: Mind, Body & Spirit

The Seventh Annual Women’s Health Fair is Saturday, September 24, from 10:00 am to 2:00 pm.

This FREE event will be held at the Women’s Health Center at 1656 North California Boulevard and the adjoining Grower’s Square Pavilion Courtyard in downtown Walnut Creek.

Leslie Griffith, KTVU Channel 2 news anchor, will give a special message at 11:00 am. Stop in to say hello at the East Bay Headache Support Group booth, and then check out the other resources and businesses which offer services and products specific to women and their families. The Women’s Health Center is part of the John Muir/Mt. Diablo Health System.

November 8, 2005: Eugene Vasin, MD, PhD (Europe), “Treating Headaches with Alternative Medicine”

Orlando, FL—Red-tinted contact lenses provided rapid, safe, nonpharmacologic relief to most patients with acute migraine pain in a recent study.

The red lenses filter specific wavelengths of light that may overstimulate retinal receptors in some migraine sufferers, resulting in the characteristic headache pain that is exacerbated by light exposure, Richard L. Garrison, M.D., reported in a poster presentation at the annual meeting of the North American Primary Care Research Group.

Dr. Garrison and colleague Kathleen Saathoff of San Jacinto Methodist Hospital in Baytown, TX, presented the results of a case series of 33 patients with a history of photophobic headache who were offered bilateral insertion of special-order red-tinted contact lenses during acute pain attacks. The light-filtering lenses brought immediate pain relief to 31 of the patients.

“With the exception of two subjects—who, in addition to migraine, had diagnoses of photophobic muscle contraction headache and pseudotumor cerebri, respectively—all of the other patients [in the study] had relief within minutes of inserting the lenses, and pain relief was maximal within 90 minutes,” Dr. Garrison reported.

All but 5 of the 31 migraine-only patients had total pain relief, and the 5 who did not get full relief had significantly reduced final pain scores of 0.5-1.5 on a 10-point visual analog scale, he said.

To control for a possible placebo effect in future randomized placebo-controlled trials, patients will be treated with contact lenses designed to filter varying wavelengths of light. The lenses then will be colors other than red.

Tinted glasses, goggles, and, more recently, contact lenses have been used to relieve pain and decrease photophobia in patients with various ophthalmologic conditions.

Because photophobia is so prominent in migraine, Dr. Garrison and Ms. Saathoff, who began investigating tinted contact lenses with patients with cone-rod dystrophy a decade ago in her work with low-vision patients, hypothesized that the light-filtering treatment might benefit migraine sufferers as well.

The inherited progressive disorder cone rod dystrophy causes deterioration of the photoreceptor cells and often results in blindness.

Tinted contact lenses were chosen over ordinary glasses with tinted lenses because the latter allow too much glare to reach the retina, both from the side and above, for sufficient filtering. In contrast, therapeutic contact lenses applied directly on the eye provide optimal filtration, Dr. Garrison said.

In the San Jacinto study, the 30 female and 3 male patients recruited for participation had physician diagnoses of migraine. All patients were instructed to present themselves for contact lens insertion during episodes of acute pain.

The special-order contact lenses were dark red and filtered 80% of the light. “The sample color was the result of trial and error from previous patients, predominantly with cone-rod dystrophy, who were extremely photophobic and may have experienced blepharospasms,” a dystonia that results in uncontrollable contraction of the muscle that causes the eye to blink, Dr. Garrison noted.

No assurance exists, he continued, “that the tint chosen for this series is optimal. The choice of tint was derived solely from experience treating a different disease. Other tints that filter different wavelengths of light may prove to be as or more effective.”

Of the 26 patients reporting total relief of all migraine pain, 5 reported complete relief within 10 seconds of the insertion of the second lens. For most patients, pain relief began within 5 minutes, and approximately 50% relief was obtained within 20 minutes, Dr. Garrison said.

It is unlikely that the migraine relief observed was a consequence of a decreased intensity of light in general. If it were, any darkening strategy would work just as well, and that’s not true, he explained. “People with migraines do seek darkness for partial relief from headache. But even total darkness only diminishes, does not ablate, headache.”

In fact, it may be that by blocking certain light wavelengths and admitting others is the key. “Whereas certain tinted filters block stimulation of migraine pain, the admission to the retina of filtered light may actually inhibit migraine,” Dr. Garrison hypothesized.

The human retina uses three cone types, with three different absorption spectra, to resolve the wavelength composition of light. These three types of cones, L-, M-, and S-cones, represent classes of photoreceptors that are primarily sensitive to long-wavelength light (L), medium wavelength light (M), and short wavelength light (S) within the visible spectrum.

The lenses used in this case series effectively blocked 90% of wavelengths of 600 nm or less and admitted 90% of wavelengths of 700 nm or more, effectively excluding stimulation of M- and S-cones and allowing selective stimulation of L-cones only, “which may account in some way for the mechanism of action,” he said.

These questions as well as others related to the comparative efficacy of other colors of lenses and other ways of selectively exposing the retina to certain wavelengths will be explored in further randomized controlled trials, Dr. Garrison stated. 0

Editor’s Note: Following are excerpts from an article about Topamax® written by Brian D. Loftus, M.D., of Houston, TX. Found on his Web site: www.loftusmd.com.

Topamax® (topiramate) is one of the newly-approved anti-epileptic drugs (AED) approved by the FDA in the past 10 years. It is considered a broad spectrum AED because it works to prevent both partial onset and generalized seizures. Topamax has potentially five mechanisms of action. They include the blockage of sodium channels (similar to many of the traditional epileptics), enhancement of GABA-a receptors (an inhibitory neurotransmitter), inhibitory effect on glutamate receptors, inhibition of L-type high-voltage calcium ion channels, and a diamox type effect. The relative importance of these mechanisms in the functioning of Topamax is not clearly known but it does not appear that any other single AED shares these five properties. Topamax is available in tablet of various sizes as well as a sprinkle form which can be used in those who cannot swallow. It is typically dosed twice daily.

Topamax lacks many of the more serious side effects seen with the older AEDs including a lack of known problems with bone marrow and an extremely small incidence of liver abnormalities apparently confined to patients with prior liver abnormalities. It does have a fairly common side effect of kidney stones (between 1-2%). It is also one of only three AEDs that have a statistically proven propensity to lose weight (Zonegran and Felbamate are the others). Other side effects include a change in taste, particularly with carbonated drinks, tingling in the extremities, and at times interference with mental function. The last side effect is highly dependent upon the rate of dose administration and is relatively uncommon among patients started at a low dose and advanced slowly. Dosing rates must be individualized based upon the patient and the other medications they are currently prescribed.

Diagnostic Clinic of Houston has participated in multiple double-blind placebo controlled studies with Topamax and we have therefore gained a lot of experience in its use for indications other than epilepsy.

Among the most common uses of Topamax is the prevention of migraines. The medication works as well for prevention of migraines as our other first class agents, meaning it works well for 50% of the patients given the medication. If one increases the dose slowly, the medication seems to be well tolerated. I would guess I discontinue the medication about 10% of the time in my practice. Some patients lose weight, as high as 15-20% of their body weight, and other patients do not lose any weight. The weight loss is generally painless for the patients and they tend to come to a new weight and stabilize there. Higher doses generally result in more weight loss. My migraine patients are generally taking from 100-200 mg per day in two divided doses.

Topamax has been shown in multiple small trials to be effective in cluster headache. Placebo controlled trials are reportedly in progress.

I have been suffering with migraines for 31 years starting at the age of 10, and during this time I have learned how to deal and live with this debilitating condition. Half of my battle was finding the right medications or combinations thereof; the other half is having the right attitude.

Finding the right medication can be a long and arduous process if you are a severe migraine sufferer like me. I have tried all of the Triptan medications, including Frova, Maxalt, Imitrex, and Relpax, just to name a few. I have also tried various preventative medicines including Inderol, Keppra, Topamax and Depakote. I have visited the emergency room countless times for injections of Demerol, Dilaudid, and Reglan. I have been hospitalized twice for 3 days at a time and received a medicine called DHE. Currently I am taking Botox injections, which seems to assist in lessening the severity of my migraine attacks.

Although research has made tremendous strides in finding relief for this condition, there remains no cure at this point. However, I am thankful for modern technology and for good doctors who have the passion and commitment not only to their practice, but also to their patients. Something that I learned over the years is that the patient must have the same passion and commitment when trying new medications as well as providing detailed feedback to assist their doctor. I am extremely faithful with using my daily headache diary. This log allows my doctor to accurately see the pattern of my migraines and give proper diagnoses and to adjust or try new medications. We must remember that the physician and patient are a team.

Your attitude can worsen or make a better life for you as a migraine sufferer. It can be extremely difficult at times to keep a positive attitude when you are constantly in pain and unable to do normal day-to-day tasks. However, I found as long as one keeps a positive frame of mind, the migraines can be handled much better. I have also found through my experiences that I became a source of encouragement for others, which in turn made me feel good and encouraged me to keep up with the right attitude. The source of my well-being and positive attitude is spirituality. Others may find it some other ways or in activities where it draws some sort of positive energy and not so much on the negativity of their current state.

Out of the two, I found that having the right attitude will always help an individual get through hard times. Medicines will come and go, but having the right attitude can live with a person forever.