Migraine and other headache conditions are a common cause of pain. Migraine headaches are the leading cause of temporary disability in the work force. Fortunately, there are many medications that can be used to prevent and treat migraines.

The first therapeutic event which needs to happen is the correct diagnosis of migraine to be made. Patients can have multiple headache types. Headaches which are severe enough to limit activity and are associated with light and sound sensitivity with nausea and sometimes vomiting are most likely migraines. Migraines usually have a pulsating, heartbeat type pain – made worse by movement.

A common type of headache which can mimic migraine is occipital neuralgia. Occipital neuralgia starts at the base of the skull. There the occipital nerve exits the spine and runs up the back of the skull to the forehead. This nerve carries pain fibers. If it becomes irritated, due to trauma, “sleeping wrong” or just routine daily activities; occipital neuralgia headache occurs. The pain can be just as severe as a true migraine. The pain can be on one side, both sides or even isolated to the front of the head. Diagnosis of occipital neuralgia is made by gently pushing at the base of the skull, over the occipital nerve. If this reproduces the headache symptoms, the diagnosis of occipital neuralgia is made. The most effective treatment for occipital neuralgia is a simple injection in the upper neck in the region of the occipital nerve.

Botox was approved by the FDA in 2011 for treatment of intractable migraines. Botox migraine treatment is not for everyone. In order to have insurance or Medicare to pay for Botox, certain criteria must be met. These criteria include:

– 15 headache days a month
– Failed various migraine prevention medications
– AEDs
– Antidepressants
– Certain blood pressure medications
– muscle relaxants
– physical therapy
– migraines must be incapacitating causing missed work or school

All of these criteria must be met before insurance will authorize and pay for Botox therapy for migraines. Once approved, Botox for migraine is a simple, in-office procedure. For experienced migraine doctors, giving Botox for migraine takes about 20 minutes. Botox does not work immediately to relieve intractable migraines. Effects can be felt as soon as two weeks but maximum benefit is at 6 weeks after Botox treatment. Duration of pain relief can be from 6-8 weeks. With repeated Botox treatment for migraine headache, there is a cumulative benefit in many patients. The minimum time in between Botox treatments is 90 days.

For optimum migraine control, affected patients should be treated every 3-4 months. This results in the best migraine control. This in combination with oral medication migraine prevention therapy.

In conclusion, Botox is effective treatment for many headache patients with chronic, intractable migraines. Proper diagnosis and treatment must be given. For insurance to pay for Botox for migraine, specific criteria must be met. If you suffer from persistent, frequent headaches, call Sarasota Neurology today for an appointment. Start improving your quality of life today.


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In October 2010, the FDA gave approval to use Botox for the preventative treatment of chronic migraine headaches. Allergen, the manufacturer of Botox, has long sought approval of Botox for migraine treatment. After conducting numerous nationwide clinical studies using Botox for headache, the most recent study, PREEMPT, showed that patients suffering from chronic migraines who were treated with Botox for preventative therapy, had significantly fewer headaches days a month than those that did not get Botox.

Chronic migraine, as defined by having more than 15 headache days a month, is one of the most disabling conditions a person can suffer from. A severe migraine can be more disabling than blindness, rheumatoid arthritis or even chest pain (angina). It is estimated that there are 3.2 millions Americans who suffer from chronic migraine. This condition affects quite commonly working aged individuals. Seventy-five percent of affected migraine sufferers are female. Migraine and headaches are a complex medical disorder which can be affected by stress, poor sleep and dietary habits. These individuals tend to overuse over-the-counter medications resulting in rebound headaches. Preventative therapy and not constantly taking abortive medication is the correct approach to managing most headache and migraine disorders. The objective is to prevent the headaches from occurring in the first place. With optimized treatment, it is usually possible to get most patients down to a manageable number of headaches per month – in our clinic four headache days or less. Only then would abortive medications be used. Narcotic medications of any kind should almost never be used for the treatment and management of migraines or headaches.

Botox is not the answer to everyone’s headache and migraine problem. This is only one of the many treatment options that headache specialists have to manage chronic migraine and other headache disorders. Careful patient selection and meticulous Botox administration are necessary to have improved outcomes in headache reduction. Not all individuals will respond to Botox, just as any other preventative medication. Botox should not be considered the first or even second line treatment for patients suffering from chronic migraine. It should be reserved for those that meet the criteria for chronic migraine and have adequate trials of most other preventative medications. Botox administration also requires a patient to receive the drug administered via a number of injections in the scalp and upper neck regions. The smallest needles are used to minimize any discomfort. If successful, a patient who responds to Botox may get as much as two to three months of relief. Getting perceived relief for only 2-3 weeks is not considered a successful response to Botox.

If you think that you suffer from chronic migraine headaches, you should call us today for a complete evaluation and then have a treatment plan designed to address your specific type of headaches.


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Migraine headaches are a common medical condition in the United States, affecting approximately 12% of the entire population. It is estimated that there are 35-45 million migraine and headaches sufferers in the U.S.  An unfortunate fact is that only 50% of all headache and migraine patients are medically treated. Individuals with different types of headaches (or migraines) are either undiagnosed or undertreated. In the 21st century, it is not necessary to suffer needlessly from migraine headache – the number one medical cause of temporary, total disability in the United States.

A new migraine medication has been approved by the FDA for use in treatment of acute migraine attacks. This new medication is called Sumavel DosePro.  Sumavel is an injectable form of the well known migraine medication: sumatriptan. Sumatriptan was first released in United States in 1992 as Imitrex injectable and subsequently the tablet form. Imitrex injectable system uses a small needle to administer the medication, sumatriptan. While this was one of the most effective treatments for acute migraine attacks, it did involve a minor needle stick. For patients who did not tolerate the thought of a needle stick, even this excellent therapy was not an option for them. Sumavel overcomes this problem by the use of a unique, needle-free injector system. Sumavel uses pressurized air to administer the medication. This is demonstrated in this video.

Sumavel comes in a self-contained injector kit. There is no need for alcohol swabs or drawing up sumatriptan into a syringe. With Sumavel a migraine patient, experiencing an acute migraine attack, needs only to snap of the safety cap, flip the small injector lever and press the injector firmly against the skin on the lower, outer abdomen or thigh. Pressurized nitrogen (a neutral gas) causes the sumatriptan change into an aerosol form and this is literally pushed through the skin into the subcutaneous tissue. This delivers a full dose of sumatriptan (6 mg) into the patient. Therapeutic effect and migraine relief can occur in as few as ten minutes. When the injector releases the pressurized air, you will hear and feel a pop noise.  There is a slight stinging sensation when the medication is pushed across the skin, but there is no needle involved. The used injector can then be disposed of in any trash receptacle. As there is no needle, special disposal is not necessary. Most insurances cover this new, novel migraine therapy.

Migraine headaches remain a major health problem in the United States. Migraines are a leading cause of missed school and work. For migraine sufferers who have too many headache attacks, this can lead to the risk of losing their job. This is unnecessary as many excellent and effective migraine control therapies are available. If you suffer from migraines, cluster headaches or any type of headache, do yourself a favor – call Sarasota Neurology for an appointment. As a migraine specialist, Dr. Kassicieh can help to improve your quality of life, control your migraines and give you your life back.


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Living in Florida is difficult for individual who have migraines and other types of headaches. This is because drops in the barometric pressure can trigger a migraine attack. During the hurricane season in Florida, there are many tropical storms, thundershowers and rarely a hurricane (or hurricanes.) There can just be low pressure weather systems sitting over Florida with no actual “bad” weather. It is not so much the rain that triggers the migraine attack as it is the lower barometric pressure. During the recent string of six different tropical storm and hurricane fronts that lasted six weeks, many patients who normal have perfectly good control of their migraines had their worst attacks ever.

It has been studied extensively as to why changes in barometric pressure, temperature and humidity have such a profound triggering effect on migraine but no definite conclusion has been reached. The effects on the outdoor environment by these weather systems, in Florida, have a profound effect on headache suffers. Not only does the change in weather trigger headache attacks but so does the increase in pollen, mold and fungus spores.

Patients will often claim that they have “sinus headaches.” True sinus headaches belong in the same category as chances of winning the lottery: 1 in 14 million. Why? Because true sinus headaches are rare. What patients are actually feeling is a milder form of their migraine headache, triggered by weather, pollen and molds. Migraine headache symptoms include: nasal congestion, sinus pressure, sensitivity to light and nasal drainage. While these are sinus symptoms, they are part of the migraine syndrome, which is a collection of symptoms associated with migraine. Patients frequently will take sinus medications that will help or stop their headache. This, unfortunately, reinforces the mistaken belief that they are suffering from “sinus headaches.” The fact is, is that sinus medications have a similar effect in relieving headaches as do those of the more specific migraine drugs.

In conclusion, more Florida patients suffer from more headache and migraine attacks during hurricane season (June 1 – November 30) than at other times of the year. About fifty percent of migraine suffers find that changes in weather will trigger their headaches. The best thing to do, if you suffer from migraines or recurrent headaches, is to seek out a neurologist headache specialist and get started on preventative headache treatment as well as migraine treatment specific medication to stop an attack. If you do suffer from allergies, there are many medications to help control this as well.


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Migraine headaches are one of the most common neurological problems seen. There are an estimated 30 million affected American patients. Despite its common occurrence, fifty percent of affected individuals remain untreated. Why are there so many patients with migraine? A new report in Neurology Reviews has shed some light on migraine risk factors and how they progress.

In this study, conducted by neurologist and headache specialist Dr. Richard Lipton, they found that patients with chronic daily headaches were more likely to be female, overweight and depressed. Other risk factors for daily headaches include head injuries and snoring. Patients also contribute to developing daily headaches by overusing analgesics such as aspirin, ibuprofen or acetomenophen containing compounds – particularly those containing caffeine. Prescription medications containing narcotics, barbiturates and caffeine for migraine treatment also increased risk of more headaches. The overuse of all pain relievers results in rebound headaches. The more headaches you have the more medication you take – the more medication you take the more headaches you have. This cycle must be broken by stopping regular analgesic consumption.

Dietary factors play an important role migraine progression. Excessive caffeine or regular soda consumption constitute significantly to increased number of headaches. Major stress events clearly contribute to migraine progression. Obesity, defined by having a Body Mass Index (BMI) of greater than 30 was associated with a five times greater risk of developing chronic daily headache. The triptan medications, such as Imitrex, Maxalt and others, are excellent choices for treating acute migraine attacks. When they are overused, they can put a patient with frequent headaches at risk for progression to chronic daily headaches. In general, individuals with four headache days per month or less, who take any of the above medications, are not at risk for progression of their headaches to daily headache. If you have more that 4 headache days per month or frequently take pain relievers for headaches, you should see a neurologist headache specialist for evaluation and treatment. The first step to improve your quality of life is to pick up the phone and call.


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Namenda (memantine) is the newest medication used in the treatment of Alzheimer’s disease. New research has shown that Namenda may be effective in treating patients with both migraine and tension headaches. The study done by John Krusz, PhD, MD showed that some patients with chronic migraines that did not do well with other headache treatments, did well with Namenda therapy. Of the migraine sufferers, there was a 56% drop in the number of migraine attacks. In patients with tension headaches there was a 62% drop in the numbers of attacks. This study was well reviewed on the website, Help for Headaches and Migraines.

Migraine and other headaches are chronic medical conditions that require aggressive preventative treatment. Many therapies have been tried but no cure has been found. Botox treatment has been promoted by the press but no clinical studies have showed that it is superior in migraine treatment than placebo. Having said that, there are certainly patients that have had migraine and headache reduction after Botox therapy.

It is important to note that the use of Namenda, Botox and most other migraine treatments are off-label uses of these and other medications. The majority of medications routinely used in the prevention of migraines are off-label. This is the standard of care in most headache clinics. If you suffer from migraines that prevent you from routine activities or interfere with work, you need to seek out help from a qualified neurologist who specializes in migraine headache treatment.


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Migraine is a very common medical condition. Migraine headaches are the second most common cause for work absences secondary only to low back pain. Unfortunately migraine is the most prevalent in the working population age group. Fortunately many new migraine treatments have been developed. The newest migraine medication that has been FDA approved is Treximet. Treximet is a combination medication. It has Imitrex with RT technology in combination with naproxen sodium (the active ingredient in Aleve.) Imitrex was the first drug in the class of triptan medications that are migraine treatment specific. Studies have shown that the Treximet formulation of the two component drugs is more effective in migraine treatment than with either drug alone. Overall, Treximet has about a 10% greater effectiveness in stopping a migraine attack with the first dose, over either of the other migraine drugs, taken alone or together.

There are several other migraine treatment medications including Maxalt, Zomig, Relpax, Frova, Amerge and Axert. All of these medications are “designer drugs” formulated specifically to treat an acute migraine attack. The most important step for any patient who suffers from headaches is to get in to see a headache specialist. Migraine and headache treatment has become a specialized area in neurology. Neurologists who treat migraine, cluster and other headache disorders take a different approach to treatment of headaches and improving the patient’s quality of life. For additional information on migraine and headache treatment click here.


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Botox is a potent neurotoxin that causes muscle paralysis by blocking the release of the neurotransmitter, acetylcholine, from the nerves that control muscles. When given under controlled clinical applications, this medication can have a dramatically beneficial effect in relieving muscle spasm due to certain conditions such as cervical dystonia, blepharospasm, hemifacial spasm and limb dystonia. Over the past several years the media has reported that Botox can relieve migraines. These claims are based on random reports of individuals who may have gotten some benefit. The manufacturer of Botox, Allergan, has conducted several nationwide studies on the use of Botox for headaches, none of which have shown a statistically significant difference over placebo. Sandra Leong writes in Natural Headache Remedies a summary about the use of Botox in the treatment of various headache disorders. She notes that one theory on how Botox works for migraine is by relieving the muscle tension. It should be noted however that physiologic studies have not shown an overall increase in muscle spasm around the head in patients suffering from acute headache attacks. It is also important to note that the placebo effect in headache studies is as high has 35%.

In a summary of the studies done by Allergan for headaches, Medical News Today lists the previous and ongoing studies that the company is conducting to analyze the potential benefits of Botox in the treatment of migraine and other headache disorders. Personally, having participated in several of these Botox trials, I would agree with the study results that there was no distinct clinical benefit from Botox over placebo. It is important to note however that these were randomized, double blind placebo studies where neither I or the patient knew if they were getting Botox or placebo saline injections. I base my conclusions on reading the final study reports. At the Florida Headache & Movement Disorder Center, we carefully screen patients with head and neck pain for the possibility of benefiting from Botox therapy. Only very few patients actually meet my criteria for using Botox for migraine treatment. Even with this careful selection of patients, our results are about 50% success rate, slightly higher that the placebo effect rate. The patients that benefit the most from Botox treatment most commonly have a high degree of muscle spasm in their neck and head, associated with but separate from their actual headaches. There have been reports by other respected headache specialists, in non-controlled trials, that Botox may effective for some patients with migraine.

In conclusion, Botox has not been shown to have a major therapeutic advantage in the treatment of otherwise intractable migraine and headache disorders. The “media hype” is without scientific basis to back up the claims cited in many reports. If you have recurrent headaches, your best bet it to be evaluated and treated by a board certified headache specialist.


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It is estimated that migraine and other headache disorders affect 30-40 million Americans. The unfortunate fact is that only 50% of these individuals seek out treatment. It is one of the leading causes of missed time from work and social functions. Untreated migraines can have a devastating effect on affected individuals’ quality of life. Migraine is one of the leading causes of temporary total disability in the U.S. work force. This is an unfortunate statistic which could be dramatically improved with earlier recognition and more aggressive treatment of migraines and other disabling types of headache. The main features of the migraine syndrome are recurrent moderate to severe headaches that interfere with activity. Associated migraine symptoms include light and noise sensitivity, nausea, occasionally vomiting and sinus congestion. Most so called “sinus headaches” are actually migraines and have nothing to do with sinus problems whatsoever. Cluster headaches are the most severe form of headache. While considered a type of vascular headache, they are put in a different category to be differentiated from migraines. This is by the International Headache Society classification of all headache disorders.

Patients experiencing a migraine attack prefer to lay down in a quiet dark room with an ice pack on their head or neck. There are excellent, non-narcotic medications that can be used to abort a migraine attack. Migraine treatments to stop an acute attack include the triptan medications such as Imitrex, Maxalt, Zomig, Relpax, Frova, Axert and Amerge. There are other medications that can be used to prevent migraines from occurring. Topamax and Depakote have FDA approval for migraine prevention. The first step is for the patient to schedule an appointment with a headache and migraine specialist.


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