Migraine Prevention

Migraine can be treated at the onset of each headache with appropriate medications. There is some evidence that those who have frequently occurring migraines may have fewer migraines if they take a preventative treatment or alter their lifestyle.

Medications that reduce migraine frequency

• Beta Blockers: unless contraindicated, beta blockers are considered the first line for migraine prevention. Asthma and perhaps depression are the most common reasons to avoid beta blockers.
• Amitriptyine: the next best treatment to beta blockers, amitriptyline is frequently used in combination with a beta blocker. The combination therapy actually has less side effects than either alone, as the medications play off each other. For example, amitriptyline produces increased heart rate while beta blockers reduce heart rate.
• Anti-epilepsy drugs: Depakote ER, gabapentin and topirimate are all useful, but each has side effects. These are the next prescription agents to try
• Calcium channel blockers: Calan (and for some others such as diltiazem) may be helpful in those who do not respond to the first line treatments.

Medications that Increase Migraine Frequency

• Narcotics: this class of medications, when taken regularly, increases the number of endorphan receptors in the brain. The body will be unable to produce enough endorphans to fill the receptors. This means that a person taking narcotics on a daily basis will actually experience more pain. Headache frequency, duration and severity wil increase.
• Ergotamines: this class of medications can lead to inflammation of blood vessels, with the result of increased headaches.

Stroke Prevention Part 1

Platelets are small blood particles that can clump together and block the flow of blood into areas of the brain. When the blockages last for only a few minutes, the effect can be a temporary impairment, such as difficulty speaking, numbness or tingling or weakness that lasts for up to a few hours. These events are called Transient Ischemic Attacks (TIAs). When the blockage lasts longer, the loss of function may not recover and this is called a stroke.

One of the important ways to prevent stroke is to prevent platelet clumping. Typically, treatments to prevent platelet clumping are started after a TIA or stroke has already occurred.

This post will cover the options for preventing platelet clumping.

Aspirin

Aspirin is the mainstay of treatment. It is inexpensive and usually well tolerated. It is often effective, typically at a dose of 81 mg per day. Higher doses (325 mg) are sometimes used at the onset of a TIA or stroke, usually just for the first dose.

Failure of aspirin to prevent ischemic events occurs in about 1/3 of all patients taking aspirin. The reasons for failure were mostly related to:

• Failure to TAKE the aspirin (just having the bottle in the home or just thinking about taking it doesn't prevent strokes!)
• A low HDL cholesterol as compared to total cholesterol (chol/HDL >2.99)
• A high resting heart rate (>69 bpm)
• Elevated triglycerides
• Patients with diabetes may have less of an antiplatelet response to aspirin, and at least one study suggests that aspirin is ineffective as stroke prevention in diabetics

So, to make sure aspirin is working for you, take it every day, do aerobic exercise daily (check with your doctor before doing this) or perhaps take a beta blocker, and take a statin to lower your cholesterol (and exercise, because exercise raises HDL).

Aspirin + Dipyridamole ER

The combination of extended release dipyridamole and aspirin is somewhat more effective than aspirin alone. This is taken twice daily. Most patients develop temporary headache during the first few days of taking this medication, which goes away within one week. Only about 80% of people who start this medication stay on it long term. The brand name is Aggrenox.

Plavix

Plavix is taken once daily. Sometimes, it may be "loaded" which means that the patient may be asked to take several pills at one time to get the blood level up quickly (usually 300 mg or 4 Plavix). The evidence so far suggests that loading Plavix is safe. When compared to Aggrenox, Plavix is equally effective in preventing strokes in the first 30 days after an event (TIA or stroke). Side effects are slightly less problematic with Plavix, at least in the short term. About 88% of people who started this medication stay on it long term. Some people are resistant to Plavix because their body is unable to metabolize Plavix into its active metabolite. These people have a genetic abnormality that leads to an abnormal hepatic enzyme (CYP2C19). This can be checked for with a blood test, and if positive, may indicate the need to use something other than Plavix or a higher daily dose. Plavix also is partially inactivated by proton pump inhibitors. If a medication to control GI acidity is needed, Zantac, Pepcid or Axid are recommended.

Plavix + Aspirin

May be best treatment for acute TIA treatment to prevent stroke, especially in non-diabetics. This combination is often used when a person presents with a TIA or small stroke. Typically, the patient is given 325 mg of Aspirin and 300 mg of Plavix in the emergency room and then placed on Aspirin 81 mg and Plavix 75 mg daily for 30 days. Beyond 30 days, there is no good evidence that this combination is superior to Plavix alone or Aggrenox.

Cilostazol

Improves cerebral blood flow and is equivalent to aspirin in stroke prevention in one small study. Cilostazol is perhaps superior to other treatments in those with lacunar strokes due to hypertension or diabetes, but this is still contraversial.

Ticlopidine

Equally effective to Plavix but less well tolerated and perhaps more adverse events. It requires lab tests (CBC, Platelet Count) to monitor its safety.

Folate (2.5 mg) + B6 (50 mg) + B12 (1 mg)

Combination prevented second stroke in 3 out of 1000 patients treated. The benefit is slight, but if a person cannot tolerate any other treatment, this is perhaps better than nothing.

Omega 3 Fish Oil

No hard data, but is being used to combat strokes.

Exercise Therapy

Exercise is vital for maintaining brain health. Before starting any exercise program, please complete the following checklist.

1. Get clearance from your health care provider for the exercise you plan to do
2. Make sure to have the proper equipment and clothingA

There are basically 4 types of exercise. Each is important for good health.

1. Aerobic
2. Strength training
3. Coordination
4. Stretching

As a general rule, neurological disorders require you to perform all 4 of the above exercises. The general rule is:

1. Gentle stretching
2. Aerobic exercise, alternating with strength training
3. Coordination exercise

Aerobic exercise

Aerobic exercise requires the heart rate to be in "the zone" which is generally 60-75% of maximum predicted heart rate. You can calculate this for yourself by using the following formula:

220 - age = Maximum Heart Rate (MHR)

MHR x 0.6 = 60% rate

MHR x 0.75 = 75% rate

Age 60% 75%

50 102 127

60 96 120

70 90 112

80 84 105

90 78 97

You should remain in the zone for at least 20 minutes per session. Continued additional benefit occurs for every minute above 20 minutes that you stay in the zone, up to 60 minutes. You can tell if you are in the zone by purchasing and using a pulse meter. These can be purchased on line and in sporting goods stores. While they can be complicated to operate, the importance of staying in the zone cannot be overemphasized. Friends, family, and even your health care provider can help you set up the equipment. This is an important part of aerobic exercise, so don't skimp and learn how to use it properly.

In general, don't outwalk or outrun your heart or your breath. If you start getting too breathless to talk, then slow down or stop.

Stretching

Yoga is the typical example used for stretching exercise.

Coordination

This usually applies to hand-eye or leg-eye movements. The best one is dancing, especially with a partner. Alternatives include racquet sports, golf, swimming, jumping rope (the last 2 can combine aerobic with coordination and are excellent combo exercises for saving time).

How often to exercise?

Minimum with benefit = 20 minutes of aerobics 3 times a week

Ideally, 30-60 minutes of exercise a day, evenly split between aerobic, coordination, and strength/stretching.

High Dose Aricept for Alzheimer's Disease

Aricept 23 mg/day may help improve mental function in patients with moderate to severe Alzheimer's Disease, even in those who have not had success with Aricept 10 mg/d.

A patient must have been on 10 mg Aricept for at least 3 months before starting the higher dose preparation.

Approximately 1/5 patients discontinued due to side effects. Side effects leading to discontinuation (usually in the first month of treatment) include nausea, vomiting, diarrhea, anorexia and dizziness.

Slowing of the heart, heart block, GI bleeding (approx 1/200) were the more serious adverse events.

Clinically Isolated Syndrome

Clinically Isolated Syndrome (CIS) is the term used for an episode that resembles an attack of Multiple Sclerosis, that may be associated with abnormalities on MRI scans of the brain or spinal cord, but that doesn't definitely prove that the person has Multiple Sclerosis. A person with a diagnosis of CIS carries an increased risk of eventually being diagnosed with Multiple Sclerosis, but the risk is not 100%.

The neurological event is most often blurred vision in one eye, but can be something else such as numbness, weakness, or unsteadiness.

It is important to let your doctor know if you have any further episodes of neurological impairment, even if the episodes last only a day or so. Also, if you happen to later remember any previous episodes of neurological impairment that had slipped your mind at the time of your doctor's visit, please be sure to let your doctor know.

Sometimes, those with CIS are advised to start medications that modify the course of Multiple Sclerosis in an attempt to ward off or delay the eventual diagnosis of MS. There is very good evidence that several medications can be very helpful in this situation, but as each person is unique, you must discuss this with your neurologist.

Foods with Gluten

While many other foods have traces of gluten, these are the ones highest in gluten.

Pretzels
Cakes
Stuffing
Muffins
Biscuits
Cookies
Pasta
Pancakes
Pastry, pie crust
Couscous
Wheat
Scones
Pizza
Foods with breadcrumbs; croutons
Barley drinks (beer); Horlicks;
Muesli

Magnesium Rich Foods

Tofu
Legumes
Whole Grain
Leafy green vegetables
Wheat Bran (shredded wheat, gran cereal, oatmeal)
Brazil nuts
Almonds
Cashews
Pumpkin seeds
Pine nuts
Pistachio nuts
Bananas
Baked potato (skin)
Cocoa powder

Calcium Rich Foods

Current recommendations are to avoid calcium supplements, but this should be discussed with your health care provider. If you are advised to increase your calcium intake, consider the foods on this list.

This is a short list of calcium rich foods:

Milk
Yogurt
Cheese
Baked beans
Sesame seeds
Almonds
Fish, especially salmon and anchovies
Pasta
Figs
Apricots
Oranges
Tofu

Welcome!

This site is for patients with neurological disorders. The information on this site should be used in conjunction with information provided by your neurologist. This site is meant as a reference, but should not be your only reference. All health care is individual, as we each are unique.

I look forward to your comments for how to make this blog better.