Down Dog it, Migraine Warrior!

We need all the angles we can come up with to fight against migraines, especially when they are frequent and hard to treat.

In a study from researchers in India called Effect of yoga as add-on therapy in migraine (CONTAIN): A randomized clinical trial, subjects with migraine and 4-13 headache days per month were randomized into a program of standard medical treatment with or without yoga. The yoga program was 1 month of supervised sessions and then 2 months of at-home yoga.

The subjects who did yoga had an average reduction of 4.4 headache days per month, compared with 0.9 fewer headaches per month for the non-yoga group. The reduction in migraine intensity was double in the yoga group and a measure of overall impact of headaches was reduced significantly more in the yoga group.

That’s a real benefit for something non-pharmacologic! I’ll be glad to share this with my migraine patients. I do always discuss lifestyle issues with people having trouble with migraine control. Of course, smart use of medications is key to a migraine treatment plan, but doesn’t always do the job entirely. We know that variations in daily lifestyle can be a trigger, such as changes in diet, hydration, exercise, sleep, or others. Why should yoga help? To those that achieve a relaxed and centered state, it’s probably a reduction in stress hormone levels that results in less pain and fewer migraine episodes. To those not as inclined to yoga, perhaps a walk, meditation, music or some other relaxing active would help.

But there’s got to be something about a discipline that’s lasted some several thousand years!

Disclaimer: I’m not your doctor and this is not formal medical advice. If you have any health concerns, check with your own health professional before starting a new exercise program.

-DS (8-30-20)

Stay one step ahead of Parkinson’s disease.

Parkinson’s disease, a degenerative condition of the brain, affects about 1% of people over the age of 60. The symptoms range from a mild non-disabling tremor to more troublesome symptoms like slowness, troubles with motor movements and troubles with balance leading to falls.

It’s known that there are some prodromal – or early – symptoms of Parkinson’s that show up some time before the main symptoms of tremor which are: rigidity, slowness and balance problems. It’s also known that physical exercise is an important part of the treatment for Parkinson’s disease along with medication, and that being physically active improves long term outcomes in people with Parkinson’s disease. Moreover, the risk of Parkinson’s is reduced in people who are typically physically active during their lives.

A study from researchers at Harvard joins these concepts together and actually shows that physical activity during young and middle adulthood is associated with reduced tendencies for even the prodromal symptoms of Parkinson’s, namely constipation, body pains, REM behavior disorder (restless sleeping and acting out dreams), daytime sleepiness, and depression. Of course these common symptoms don’t always necessarily lead to the development of Parkinson’s, but it still lends support to the benefit of exercise not only for Parkinson’s, but other problems as well. And the degree of protection from these symptoms associated with physical activity was similar to the protection from developing Parkinson’s. So it seems there must be some link supporting the robust benefit of exercise across the spectrum of Parkinson’s disease.

It’s hard to find any evidence against exercise as beneficial for the aging human. Of course, I must mention: please don’t embark on a major exercise regimen without advice from your doctor, especially if you have any health concerns. And based on my personal experience, don’t expect you can keep up with your 13 year-old budding cross-country running star. This leads to body pains and an unnecessary sense of failure.

-DS (8-10-20)

We’re all a little sick.

One of my mentors in neurology at Yale was making a point to me as we were struggling to figure out how to help an intractable headache patient in clinic one day. Literally nothing helped this person. No standard treatment made any difference. All her tests were normal and she appeared totally normal, yet had headaches all day every day that she described as the worst pain imaginable. As you can imagine she was also very anxious and had a lot of stress. In this situation we always say, “Well of course the patient has anxiety, she has daily intractable headaches.” His point to me, however, was sometimes a symptom such as headache can be part of a person’s mindset more than anything else. It just may be the way they express distress. Maybe the headache is caused by the distressed mental state and not the other way around. What he said to me was, “Just sit for a while and think about your head. If you try, you can talk yourself into a headache.” I tried it and found out that he was right.

I’ve always tried to experience what my patients do whenever I can. I know what carpal tunnel feels like after riding a road bike for a long time. I’ve had a migraine visual aura. We’ve all had anxiety, palpitations, insomnia, headache, and we’ve probably all felt dizzy, including the “head rush” of standing up too quickly. But there’s a huge separation between symptoms and sickness.

In an article called “Persistent postural perceptual dizziness is on a spectrum in the general population,” researchers theorized that PPPD, a life changing and disabling condition in many, is present to some degree in many normal people. PPPD is a feeling of dizziness or a non-spinning vertigo provoked by complex visual stimuli or movement. The study showed that many normal people report having the same symptoms as a patient who is “sick” with PPPD. This was demonstrated by two questionnaires given to PPPD patients and a group of healthy volunteers and students.

One of the questionnaires used in the study, the Visual Vertigo Analogue Scale (VVAS) looks at nine items including: walking in a supermarket aisle or shopping mall, riding in a car, being under fluorescent lights, watching traffic go by, going down an escalator, watching a movie in a theater or action on TV, and walking on a patterned floor. All of these stimuli can cause disabling symptoms in a person with PPPD. But many people have these symptoms without being distressed by it. In other words they have the symptoms but they aren’t sick. The study found that, depending on the group and the measure, between 4% and 54% of non-patients scored greater than a 25th percentile range of patients with PPPD. The authors theorize that these symptomatic but not sick people are an at risk group that may develop the disease if they suffer some insult such as labyrinthitis (an inflammation in the inner ear sometimes from a viral infection), or a concussion for example. It’s an interesting question.

To me, though, it begs another question: “If you think about your head long enough, can you feel dizzy?” If I’m standing by a tree and look up at it, I feel fine. I can look up into the tree and look down again and it doesn’t bother me. I’ve been to the Empire State Building and I’m afraid of heights so I feel nervous up on the observatory. If I’m standing on the observatory and then look up at the radio tower above it I feel nearly like I’m going to fall. It’s my situational PPPD. Why is that? Maybe I’m starting with that uneasiness of being up high and it predisposes to a distressing feeling that doesn’t happen on the ground by a tree.

I think about these things, and wonder: that patient of mine that has trouble walking into a supermarket – how can I help them make that their tree, rather than their radio tower?

-DS (5-23-20)

Who needs a migraine after surgery?

For those with migraine, the presence of many potential triggers can be a daily minefield.  There are avoidable triggers (certain foods, drinks, activities or habits) and there are unavoidable triggers (menstrual cycle, weather or external stress.)  It’s pretty obvious that something like surgery could be a migraine trigger.  Really any physiologic disruption can trip the migraine switch.  A recent article looked at this issue specifically.

In The association between migraine and hospital readmission due to pain after surgery: A hospital registry study, researchers reviewed records from over 150,000 subjects who had surgery for any reason and found that the presence of a migraine diagnosis increased the chances for a readmission to the hospital for pain by 42% over post-operative subjects with no migraine history.  It would therefore seem that surgery is triggering something.  If the data was filtered for  headache or abdominal pain (both of which are seen with migraine attacks) the increased risk was 55%.

This concept was then explored further in a presentation at the 2019 American Headaches Society Meeting in July in which the same team presented data from 22,000 migraine sufferers who had surgery for any reason to look at how pain medication prescription affected readmission rates for pain.  The study found that if a post operative migraine sufferer was given a non-narcotic migraine abortive they were 37% less likely to have a readmission for pain after surgery and if they were given a migraine specific medication such as a “triptan” medication, the figure was a 67% lower likelihood of a pain-related admission.

All this seems intuitive but putting some figures on it is interesting.  In particular, this seems to prove the effectiveness of the migraine specific “triptan” class in dealing with even post operative migraines and keeping people out of a hospital.  This class includes sumatriptan (Imitrex), eletriptan (Relpax), rizatriptan (Maxalt), and others.

Who needs a migraine after surgery?  Who needs a migraine any day?  If you have poorly treated or untreated migraines, best to see your doctor and get access to the very good prescription medications out there to deal with this.  A primary care doctor can be the first stop, but neurologists are expert in this condition and can be a good source of information and relief options.

-DS (5/9/20)

Why older folks should go to camp.

A quick search of summer camp options in my area reveals daytime or sleep away camps with activities including the following:  nature exploration, musical theater, rock music performance, fencing, robotics, cartooning, rocket space science, sailing, circus arts, computer coding, zoo veterinarian shadowing, architecture, to name only a few.  And that doesn’t even include all the usual traditional sports involving courts, water, grass and dirt.  If only there were summer camp for older adults!  I suppose it does exist in other venues and by other names.  The key is to have the time and inclination to seek out such stimulating activities.

A recent article published in the journal Neurology, suggests that stimulating activities like these summer camp offerings may benefit older adults.  The article, called Frequency, number, and timing of mental activity and risk of mild cognitive impairment, examined the typical activities of a group of study participants at least 70 years old.  The aim of the study was to see if mentally stimulating activities (like those great summer camps) correlated with decrease chances of cognitive decline with age.  In the study the particular activities of interest were: book-reading, craft activities, computer activities, game-playing, and social activities.  The 2000 subjects in the study were followed for 5 years and underwent cognitive testing to look for onset of what we call Mild Cognitive Impairment (MCI), a potential precursor to a more disabling condition we call dementia.

The findings showed that people who engaged in more of these activities, especially at older ages, were less likely to develop MCI.  Compared to people without any of these activities, engaging in one of them reduced the chances of MCI by 20%.  People who engaged in all 5 of these activities saw a reduction of 43%.  That’s a big number and beats the effect of our best medications for dementia by a mile!

Of course this kind of study can give misleading results:  maybe it’s not the activity that keeps people sharper, maybe it’s the sharper people that are drawn to these activities.  But there is the concept of “cognitive reserve” that has been shown in other studies and that this study probably supports.  Cognitive reserve means that even though the brain structure may deteriorate with age, or the first protein plaques of Alzheimer’s disease may appear, people with cognitive reserve from a more stimulating life experience don’t manifest cognitive changes as early as people who never built up their brain power in life.

It certainly can’t hurt to be social, play games, and read books.  And if the effect is half what it seems in the study, that’s pretty good!  So go out there and find the equivalent of summer camp!  The kids seem to enjoy it.

-DS (8-23-19)

See also:

Tough job? Look on the bright side!


Improve memory with music or meditation.

News reports of the death of aspirin are exaggerated.

Late last year a number of news reports seemed to say the aspirin doesn’t work to improve health or prevent adverse health events.  Like the one linked above, these stories presented the truth about aspirin based on several studies published in the New England Journal of Medicine.  But the headline that too many people heard or believed was “aspirin doesn’t help so stop taking it.”

A bunch of my patients called and said that they were worried and were stopping aspirin based on these reports in the media.  Most times they didn’t hear the whole story.

The NEJM studies were looking at otherwise healthy older people taking aspirin just for possible pure health benefits (such as preventing a first heart attack or lowering the risk of cancer.)  This is the group in which aspirin was not beneficial.  We call that “primary prevention.”  Meaning, treat the common disease before it shows itself.  Aspirin doesn’t work for this concept, or at least we’ve never proven that it does and these studies support that lack of benefit.

My patients, most of whom are on aspirin following a stroke or TIA, are in a different situation, called “secondary prevention.”  Secondary prevention means there’s been a stroke, or heart attack or claudication (artery blockage) in the legs and we’re trying to minimize the risk of further problems.  For this, aspirin remains a mainstay in long term treatment.  The risk is higher because the disease has declared itself, and so the benefit of a treatment with a small risk (bleeding) is worth it.

We can tolerate a low risk of bleeding if the aspirin has a good effect for reducing the chance of another stroke.  Aspirin reduces these problems by making the blood less likely to clot.  When you diminish clotting, you increase bleeding.  In all comers without a high risk of clotting, even that small risk of bleeding doesn’t make sense.

So what do we do for primary prevention?  Control blood pressure, lower cholesterol, treat diabetes, eat a health diet, exercise and avoid obesity, don’t abuse alcohol and don’t smoke.

Of course every person is different and there may be some situations in which aspirin as primary prevention may be reasonable.  This is best discussed with your doctor to figure out what makes the most sense to you.

Here are links to the NEJM articles.

Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly

Effects of Aspirin for Primary Prevention in Persons with Diabetes Mellitus

Effect of Aspirin on All-Cause Mortality in the Healthy Elderly

-DS (5-25-19)

Cognition by numbers

Here’s some numbers for you.

In a study called Exercise for cognitive brain health in aging: A systematic review for an evaluation of dose, researchers performed what is called a meta-analysis of many studies on exercise and cognitive decline to see if they could determine a “dose” of exercise that is required to make a difference.  They found that the number was 52 hours over 6 months.  The subjects in the studies ranged from having normal cognition (59%) to mild cognitive impairment (26%) to dementia (15%) and were assessed for “improvement in cognitive performance.”  Since this was a compilation of many studies, one caveat is that each study may have measured cognitive performance differently.  So something on the order  of 2 hours per week is what it seems to take to make a difference.  This is basically in line with recommendations from the U.S. Office of Disease Prevention and Health Promotion which recommends 75-150 minutes of vigorous or moderate intensity exercise per week for general health.

Here’s another couple of numbers on sleep and cognition:  5 and 10.  In a study called Association Between Daily Sleep Duration and Risk of Dementia and Mortality in a Japanese Community, researchers followed 1500 Japanese subjects older than 60 for 10 years while surveying them on sleep duration.  They fond the highest rates of dementia or death in those that slept either less than 5 hours per night or more than 10 hours per night.  There was also an increased risk of dementia in those taking sleeping medications.

There you go.  52, 5 and 10.  To boil it down, exercise about 2 hours per week and if you’re sleeping less than 5 or more than 10 hours per night, talk to your doctor about it.  Maybe it’s just the way you are, but worth looking for an issue like obstructive sleep apnea or other nighttime issue that can interfere with sleep.

-DS (11-5-18)

Sleep and cognition

It goes without saying that sleep is important.  Some people need more than others and the rare person can perform well mentally on low amounts of sleep routinely.  (I envy those people!)

Recently, two articles looked at sleep and cognition.  The first was called Sleep and cognitive decline: A prospective nondemented elderly cohort study, and looked at 2893 Korean adults older than 60 years.  Around 2200 were considered cognitively normal and the rest had Mild Cognitive Impairment (MCI.)  MCI means that there is cognitive loss considered to be more than normal for age, but not disabling.  When cognitive decline is disabling, that’s when we call it dementia.  The subjects in the study filled out questionnaires about sleep at the beginning of the study and were reassessed 4 years later.  The study found that longer sleep latency (taking more than 30 minutes to fall asleep) and longer sleep hours (more than 7.95 hours) were both associated with increased risk for cognitive decline in the initially normal subjects.  There was 40% and 70% increased risk, respectively.  Surprisingly, a later midpoint of sleep (after 3AM) was protective and associated with a 40% reduced chance of developing cognitive decline.  (So much for early to bed early to rise!)  But remember these are just associations.  It’s not proven that certain sleep habits increase dementia.

While the above study looked at general sleep habits, another recent study looked at sleep deprivation and levels of toxic β-amyloid, the substance thought to cause Alzheimer’s disease.  The study, called β-Amyloid accumulation in the human brain after one night of sleep deprivation, took 20 healthy volunteers and performed a PET scan that images levels of β-amyloid after a night of normal sleep and a night of complete sleep deprivation.  They found that amyloid was higher in key parts of the brain after sleep deprivation.  This study doesn’t prove at all that sleep deprivation causes Alzheimer’s disease but it is very interesting that a potentially problematic brain waste product is cleared out with sleep and not cleared out without sleep.

I wouldn’t lose sleep over any of this!  If you are an early sleeper and early riser that’s just you!  If you need 9 hours of sleep to feel normal, that’s ok too!  But listen to your body and brain and get the sleep that you feel you need, when you need it.  And while you’re awake use the time to get your brain plenty of stimulating activity along with physical exercise.

-DS (8-9-18)

Demoralization in Parksinson’s Disease

Demoralization is a psychological state characterized by helplessness, hopelessness and a sense of failure.  It often but not always goes along with depression.  We know that depression is common in people with Parksinson’s disease, as with other chronic disabling conditions.  A recent article finds the not surprising fact that people with Parkinson’s often also have symptoms of demoralization.

The study, called Demoralization in Parkinson disease, researchers gave questionnaires to patients with Parkinsons disease and similar people without Parksinson’s disease.  The questionnaires focussed on symptoms of depression and demoralization.  Demoralization was present in about 18% of people with Parkinson’s disease and about 10% of similar people without Parkinson’s.  Not all people with demoralization had depression and vice versa.  I would think of it this way:  depression is a result of an imbalance in brain chemistry that causes symptoms like low energy, lack of interest, poor concentration, changes in appetite and in the worst cases, suicidal thoughts or actions.  Demoralization is more of a mindset of hopelessness and failure not necessarily along with the spectrum of symptoms of depression.

We think about and treat depression often with medications which work well.  We don’t often think in terms of demoralization, though, because it’s not really a medical diagnosis.  The importance of this article is the fact that demoralization, when present, can be treated, but differently.  Cognitive behavioral therapy (CBT) with a psychologist seems to work better for demoralized feelings than the medications we use for depression symptoms.  CBT is also used for m any different psychological problems including depression, often along with medication.  CBT treatment, which helps a person retrain the way they think, takes time and effort, but as the best treatment option for demoralization it may be worth it and may help the person with Parkinson’s enjoy a better quality of life.

-DS (7-16-18)

Laser shoes for Parkinsons gait freezing.

One of the more difficult issues to deal with in folks with Parkinsons disease is gait freezing.  That’s where the person stands in one place unable to start walking.  The first movement of a foot off the ground just won’t happen.  It can be quite disabling and, as I’ve seen in my waiting room many times, it can be socially embarrassing.  There’s a performance anxiety component in many folks which makes it happen more often in public than at home.  We try various “tricks” to get that first foot moving, such as marching in place first or pretending to step over an imaginary line.  There are rollator walkers with a laser light that shines just ahead of the person to provide a line to step over and there are canes that also have lasers to put a spot on the floor to aim at.  For whatever reason, stepping on a target can help overcome the freezing.

Enter the “laser shoes.”  In an article called The laser shoes: A new ambulatory device to alleviate freezing of gait in Parkinson disease, published in the journal Neurology, researchers designed a shoe attachment that shines a laser projection from the shoe itself onto the floor, for people who don’t otherwise need a cane or walker.  (Of course you can also just carry a laser pointer, but that’s not all that convenient.)  They found that the laser shoes reduced the number of freezing episodes by about 30-50% depending on how effective there medication was at the time.  (For those who know, the “off” or “on” state.)  Most in the trial expressed a desire to buy a laser device.  That’s a pretty good endorsement!

In case your wondering, the device can be purchased.  As a doctor, I’m not formally recommending it and I have no experience with it.  But here’s the link.  I also have no financial interest whatsoever, of course.

-DS (7-10-18)