Richard G. Petty, MD

Cluster Headache: A New Approach

By a strange "coincidence", just a couple of days after posting about cluster headaches, the BBC is carrying an article about a woman with cluster headache who was successfully treated by a neurosurgeon who implanted a nerve stimulator attached to the greater occipital nerve at the back of the skull.

It has been known for some time that there is a type of atypical cluster headache that can be treated by blocking these nerves. Some experts feel that since cluster headache
is usually driven by the hypothalamus, headaches that can be stopped by
nerve blockade or nerve stimulation are not cluster headaches at all.

That is something for us to sort out at scientific conferences.

But for now, there is at least one person – who was featured in the BBC’s article – who has been cured after everything else failed.

But here’s the strange thing: none of the neurologists or neurosurgeons has a clue how the treatment works.

Yet anyone versed in Traditional Chinese Medicine would tell you immediately the nerve runs directly above a key acupuncture point – Fengchi, or Gallbladder 20 – that is often used in treating severe headaches. Because disturbances in the subtle systems of the liver and gallbladder are common in many types of headache.

In other words, knowledge of the subtle anatomy of the body can explain how the nerve stimulator is working, but the best of current Western neurological science cannot.

A beautiful example of how the combined approaches of Integrated Medicine can help and inform everyone involved.

And it is the patient who gets all the benefits.

Cluster Headache

There are dozens of types of headache, but one of the most serious and debilitating is called “cluster headache.”

It is a very severe headaches of a piercing quality that most often occurs near one eye or temple. The pain typically lasts for fifteen minutes to three hours. The headaches are usually
unilateral and occasionally change sides.

It is difficult to overstate the severity of the pain. I once mentioned that I could always tell if there was someone in the clinic experiencing a cluster headache because everyone could hear him banging his head against the wall to try and get some relief. They may also be described as “suicide headaches:” a reference to the
excruciating pain and resulting desperation that has culminated in
actual suicide.

There are some odd symptoms that may accompany the headache, such as:

  • Stuffy or runny nose in the nostril on the affected side of the face
  • Red, flushed face again on the side of the headache
  • Swelling around the eye on the affected side of the face
  • Reduced pupil size
  • Drooping eyelid

As the name implies, cluster headache usually comes in clusters that last for a week or two or as long as two months. In about 10-15% of people they are chronic. The periodicity of the clusters is remarkable and has lead many of us to speculate an involvement of the brain’s “biological clock” or circadian rhythm. In an observational study we found that clusters were more likely to begin in the month of birth of the sufferer, though we never knew how much to read into this.

Cluster headache is far more common in tall men: most are over six feet tall. When we first described cluster headache in women in the early 1980s it was a rarity, though more women have been getting cluster headache in recent years: we have no idea why. Some years ago we also described that they were more common in men who smoked heavily and drove more than 15,000 miles each year. It was impossible to say whether the smoking was cause or effect. Cluster headache is, along with diabetes and multiple sclerosis, an illness that becomes more common in peple who live far from the equator.

We and others also found that nitrates could trigger episodes in some people: that first came to light when we saw three men who used them during sex.

Cluster headaches are most likely to be due to an abnormality in the hypothalamus, which could explain why cluster headaches frequently strike around the
same time each day, and during a particular season, since one of the
functions the hypothalamus performs is regulation of the biological clock and the metabolic abnormalities that have been reported in some patients.

During the onset of a cluster headache, the most rapid abortive treatment is the inhalation of pure oxygen (12-15 litres per minute in a non-rebreathing apparatus). When used at the onset of headache this can abort the attack in as little as 5
minutes. Once an attack is at its peak, using oxygen therapy appears to
have little effect. Alternative first-line treatment is subcutaneous
administration of triptansumatriptan and zolmitriptan. Because of the rapid onset of an attack, the triptan drugs are usually taken by subcutaneous injection
rather than by mouth. While available as a nasal spray, it had been thought that the spray would not be effective to sufferers of cluster headache due to the swelling
of the nasal passages during an attack. However new research from London has shown that 5-mg and 10-mg doses of zolmitriptan intranasal spray are effective within 30 minutes and well tolerated in the treatment of acute cluster headache.

Lidocaine (or any topical anesthetic) sprayed into the nasal cavity may relieve or stop the pain, normally in just a few minutes, but long term use is not suggested due to
the side effects and possible damage to the nose and sinuses

Previously vaso-constrictors such as ergot
compounds were also used though less so now becuase of their side effects and new options being available. Oddly enough some sufferers report a similar relief by
taking strong cups of coffee immediately at the onset of an attack.

Many different types of prophylaxis have been tried, with lithium, the calcium channel blocker verapamil at a dose of at least 240mg daily, and the anticonvulsant topiramate.

Now a new report in the journal Neurology suggests that 22 out of 26 people with cluster headache who used psilocybin reported that the drg aborted their attacks. 25 of 48 psilocybin users and 7 of 8 LSD users reported cluster period termination; 18 of 19 psilocybin users and 4 of 5 LSD users reported remission period extension. The authors conclude that research on the effects of psilocybin and LSD on cluster headache may be warranted.

From what we do understand about the pathogenesis of cluster headache it is not difficult to see how psilocybin and LSD may help. But it did worry me that this report might lead to people self-medicating with hallucinogens without any kind of support or guidance.

That being said, this recent report shows once again the importance of listening to what people have to say: they often have the answers inside of them. And those answers may lead to a new range of treatments.

Music Therapy

Music therapy has been in use for millennia: in the Bible David played his harp to try to ease the suffering of King Saul and there are whole systems of musical healing in the traditional healing systems of China and India. I have commented before on the extraordinary power of music.

Apart from our experience, there is an astonishingly large and diverse body of scientific literature on music therapy, not just to help individuals, but also on possibly improving the performance of health care providers. Many surgeons attest that they do a better technical job if they are listening to music.

This month’s issue of the British Journal of Psychiatry carries an interesting article about the value of music therapy in people with schizophrenic illnesses. Though small, it indicates that music therapy can be helpful, and speaks to the integrity of many components of the nervous systems of people with this large and diverse group of problems.

There is good evidence that music therapy may help with:

This is by no means an exhaustive list: I have found several hundred studies, many of which are quite well designed. There are also several professional organizations such as the American Music Therapy Association.

It is clearly important to choose the right kind of music: I would guess that Metallica is less likely to soothe the fevered brow than Steve Halpern.

Background music can be wonderful for improving the ambience of your home or workplace. But you can also be more focused in your use of music to help or support other types of health and wellness programs.

Select the music that you like: there are now many wonderful programs geared toward using music for healing: I can give you a list of some that I have tested. The good ones will entrain your heart rate, some of your brain rhythms and the subtle systems of your body.

If you can find 20 minutes, the right music listened to while sitting or lying with your eyes closed can be as effective as a short meditation. For this to work well, it is best to use good quality headphones and to allow the music to wash over and soak you like a warm bath, while gradually slowing and deepening your breath.

I’ve also made extensive use of specifically chosen music during massage, acupuncture, yoga, and while practicing t’ai chi ch’uan and qigong. Some purists don’t like using music while doing these activities, but I’ve usually found that music can enhance each type of practice.

Try it and see what you think.

Qigong in the Treatment of Depression

I first started teaching T’ai Chi Ch’uan and qigong over 20 years ago, and I was always impressed by the apparent benefits for people with chronic low mood. Not so much in people with severe depression, but in people who were just chronically miserable.

During a visit to Hong Kong in 2004, I heard about some interesting research that’s just been published. Researchers from the Department of Rehabilitation Sciences at the Hong Kong Polytechnic University and Kwai Chung Hospital, examined the effects of regular qigong in 82 older people with a diagnosis of depression. After just eight weeks of regular daily practice, there was an overall improvement in mood, self-efficacy and personal well-being. By week sixteen there were really quite marked improvements not just in mood, but also in activities of daily living and how people felt about themselves.

We know that there are close links between mood and the immune system, so this research fits in with a study from Tokyo in which a breathing method said to enhance Qi was shown to reduce stress and modulate the function of the immune system.

There are many studies of qigong, but they are of variable quality. Another one which supports both of these two studies comes from Korea, where something slightly different – qigong therapy – was shown to help both pain and mood in older people with chronic pain form a variety of causes.

I do not think that we have enough evidence to try using qigong alone in the treatment of depression, which is, after all, a potentially fatal condition. But I do think that Qigong is an important part of an Integrated Medicine program, and I am creating more resources for people to do the first stages of qigong on their own.

Curing Chronic Pain: Its All Done with Mirrors

There is a fascinating new approach to treating chronic pain.

The story goes back two years, to the publication of important research from a team at the Royal National Hospital for Rheumatic Diseases, in Bath in England. They wrote a paper in which they tried to link joint pain in neurological conditions. They wanted to see how the pain of rheumatoid arthritis, fibromyalgia and complex regional pain syndrome might relate to phantom limb pain (PLP) experienced by many amputees.

They suggested that in each condition there is reorganization in the sensory regions of the cerebral cortex. And it is this reorganization that generates pain and an altered body image. It seems to be just the same in rheumatology patients as has previously been hypothesized for amputees with PLP; that is a motor/sensory conflict. The body and the sense don’t match and it hurts. Their initial research indicated that something incredibly simple: using a mirror could help people correct of this conflict. They were able to show that a mismatch between motor output and sensory input creates sensory disturbances, including pain, in rheumatology patients and also in healthy volunteers.

In a second paper the investigators were able to show that doing a movement while looking at a distorting mirror could quickly induce uncomfortable symptoms in fit healthy people.

For over two decades, David Blake – the senior author of this research – has championed the idea that there is an important neurological component in inflammatory arthritis. It all started with a simple observation that has puzzled generations of clinicians: why is it that joint involvement in inflammatory arthritis is so often symmetrical? It isn’t surprising if both hips get arthritis: they will likely both have been subjected to a lot of wear and tear. But why should arthritis involve the second joint of the index finger in both hands? It has always looked as if this might imply some neurological contribution.

The idea is that although pain may have originated in inflamed joints, it is maintained and exacerbated by the nervous system. This fits with a fact that has been known to acupuncturists for centuries and has been replicated in pain clinics around the world. If you can interrupt what we call the pain cycle – constant chronic pain that feeds on itself and gets progressively worse – then you may often see pain relief for weeks or months, or sometimes even indefinitely. It is quite common for chronic pain to have had a clear physical precipitant, but to be maintained by key regions in the brain.

This new research strongly supports these observations, implies that the successful treatment of chronic rheumatological pain may involve a neurological approach, and offers a brand new therapeutic option.

“The speaker is only a mirror. Where you can see yourself. When you recognize yourself clearly, you can put aside the mirror.”–Jiddu Krishnamurti (Indian Spiritual Teacher, 1895-1986)

“Perception is but a mirror, not a fact. What I look on is my state of mind reflected outward.”–A Course in Miracles

Peripheral Neuropathy

Treating peripheral neuropathy can be one of the toughest problems facing a clinician. Peripheral neuropathy simply means disease affecting the peripheral nerves.

There are a great many cause of peripheral neuropathy. This is just a partial list to give you an idea of the things that a clinician has to think about before starting treatment:

  1. Metabolic illnesses: Diabetes mellitus; porphyria; chronic renal failure; amyloidosis and disturbances in circulating proteins
  2. Vitamin deficiencies: Vitamins, B1, B3, B6 and B12
  3. Drugs and chemicals: Alcohol; Heavy metals like arsenic, lead and mercury; organic pesticides; several drugs used in cancer chemotherapy; isoniazid; nitrofurantoin
  4. Infections: Lyme disease; Herpes zoster (shingles); Diphtheria; Brucellosis; Leprosy; Tetanus; Botulism
  5. Malignant illnesses
  6. Inflammatory and autoimmune illnesses: Rheumatoid arthritis; Systemic lupus erythematosus; Polyarteritis nodosa; Sarcoidosis; Guillain-Barre syndrome; Celiac disease
  7. Physical injury: Trauma, stretching and compression of nerves, which can include things like carpal tunnel syndrome.
  8. Congenital illnesses

Many causes of peripheral neuropathy, particularly diabetes, may also damage the autonomic nervous system that controls the heart, blood pressure, swallowing, intestinal and bladder function.

Neuropathic symptoms typically start in the feet, because the nerves running down there are longer and more vulnerable than the ones going to the hands.
The most common symptoms are:

  1. Numbness
  2. Tingling
  3. Abnormal sensations called dysesthesias
  4. A characteristic form of pain, called neuropathic pain or neuralgia: people usually describe it as “pins and needles,” a steady burning sensation or “electric shocks.” These pains can be difficult to describe: typically pains, like stubbing your toe or stepping on something sharp, are transmitted through pain fibers. Neuropathy also involves other neurological pathways, so that the brain receives impressions that it cannot process.

There has been a revolution in out understanding of neuropathic pain in recent years. It is now considered to be a disease rather than a symptom. Normal pain is designed to protect you: you put your foot on a hot plate and you pull it away immediately. Neuropathic pain is different: it is non-protective and it persists and therefore behaves like a disease.

Multiple different classes of medications have been shown to be effective in some people with neuropathic pain, though most are not approved for use by the Food and Drug Administration:

  1. Lidocaine patches and creams
  2. Capsaicin creams
  3. Opioid analgesics
  4. Tricyclic antidepressants
  5. Serotonin-norepinephrine reuptake inhibitors (SNRIs)
  6. Anticonvulsants: Carbamazepine; gabapentin; pregabalin

Earlier this week, data presented at the European Federation of IASP (International Association for the Study of Pain) Chapters (EFIC) indicated that an innovative combination of painkillers might hold the key to unlocking the severe and relatively untreatable pain of peripheral neuropathy.

Dr Magdi Hanna, Director of Pain Clinical Research Hub at King’s College Hospital in London, has been studying the combination of the strong opioid oxycodone (OxyContin) with gabapentin (neurontin) in over 300 patients with severe diabetic neuropathy. This combination demonstrated a significant 33% improvement on top of the best pain relief achievable using the maximum tolerated dose of gabapentin as monotherapy. The study was part funded by one of the medicine manufacturers.

This study is good news, but even in this study there were a great many people who were not helped. In another blog item, I’m going to talk about some of the unorthodox approaches that have helped some people.

Cutting and Self-injury

There’s an extremely disturbing trend: ever-increasing numbers of young people who are cutting themselves. Once rare, and something usually seen only in people with serious psychiatric illness, many school children encourage and goad each other into doing it, and there are websites dedicated to cutting, on which young people compare notes and even give each other advice on how to conceal what they are doing, by cutting themselves in places like the lower back.

We have been offered a great many explanations for this worrying development, but not much in the way of evidence. We know that most people who cut themselves are female adolescents or young adults, and apart from the obvious physical dangers, there is evidence that this behavior may lead to a more serious psychological condition called Borderline Personality Disorder. This can be a serious problem that carries a high risk of suicide. It is also of some theoretical interest, because there seem to be genuine cultural differences in borderline personality disorder. An estimated 5.8 million to 8.7 million Americans, mostly women, suffer from it, but it is far less common in most of Western Europe and Australia. Research over the last decade has indicated that the condition is becoming more common in these regions. People with the borderline personality disorder have a wide spectrum of difficulties that are marked by emotional instability, difficulty in maintaining close relationships, eating disorders, impulsivity, chronic uncertainty about life goals and addictive behaviors such as using drugs and alcohol. They also have major impact on the medical system by being among the highest users of emergency and in-patient medical services. Glen Close’s character Alex Forrest in the movie Fatal Attraction, had some of the features that we might expect in some with borderline personality disorder.

Researchers from the University of Washington in Seattle have reported that adolescent girls who engage in cutting behavior have lower levels of the chemical transmitter serotonin in their blood. They also have reduced levels of activity in the parasympathetic nervous system as measured by what is called respiratory sinus arrhythmia, a measure of the ebb and flow of heart rate as we breath. Low levels of this measure are typically found in people who are anxious or depressed. The study included 23 girls aged 14 to 18, who engaged in what psychologists call “parasuicidal” behavior. Participants were included if they had engaged in three or more self-harming behaviors in the previous six months or five or more such behaviors in their lifetime. The comparison group consisted of an equal number of girls of the same ages who did not engage in this behavior.

In line with previous research, the adolescents in the parasuicide group reported far more incidents of self-harming behavior than did their parents.

The findings of low serotonin and low parasympathetic activity support the idea that the inability to regulate emotions and impulsivity can trigger self-harming behavior. The primary problem is an inability to manage their emotions: the people who cut themselves have excessively strong emotional reactions and they have extreme difficulty in controlling those emotions. Their self-harming behavior may serve to distract them from these emotions.

A characteristic feature of borderline personality disorder is not just self-injurious behavior but also stress-induced reduction of pain perception. Reduced pain sensitivity has been experimentally confirmed in patients with the condition. The increasing incidence of the condition in Europe is attracting many European investigators and colleagues from Mannheim in Germany have recently traced the neurological circuits involved in this stress-induced reduced pain perception.

There is good evidence that people who cut themselves are more likely to have been victims of sexual abuse or violence as children, though that obviously does not mean that every person who harms themselves has had something bad happen to them in childhood. Sadly the research has become more complex because of the numbers of people who have been given false memories of abuse by well-meaning psychologists.

Treating people who cut themselves, whether or not they have borderline personality disorder can be very challenging. The first thing is to treat any underlying mood or anxiety disorder. A combination of medications and psychotherapy is normally used, with people making claims for the value of different types of therapy. Many therapists also say that they have helped people who cut themselves with tapping therapies, acupuncture, homeopathy and qigong. I’ve not been able to find any credible research evidence to support the use of those therapies, though I’ve also seen some success stories.

We also have the puzzle about why cutting and borderline personality disorder seems to have been less common in other parts of the world and are now increasing. There is research to show that it’s not just a matter of recognition or of calling the illness something else in Europe. I have a friend who is a senior academic at an Ivy League University, and an expert on borderline personality disorder. During a sabbatical in Scotland some 15 years ago, he could not find a single case. This matters, because if we can identify what’s changed, we may have some clues about treatment. There are hundreds of candidates, including environmental stress, diet and toxins.

There’s an important new study in which 13 children with autism showed marked improvement in some of their challenging behaviors when they were given 1.5gms of omega-3 fatty acids each day. This was only a six week study, but it needs to be replicated using larger numbers. It is also important to be alert to the possibility that some makes of omega-3 fatty acids on the market contain mercury. The one that we have found best so far has been OmegaBrite. It will also be useful to see if dietary supplementation will help self-injurious behavior in other types of people.

Here is a list of some of the better information sites about self-harm.

The key to success with helping complex problems, as I point out in great detail in Healing, Meaning and Purpose, is a comprehensive approach:

Combinations are Key

Fibromyalgia and Childhood Abuse

There is a small and growing literature about a link between fibromyalgia and a history of abuse, primarily in childhood or early adolescence.

A new study has shown that people with fibromyalgia who had experienced physical abuse in childhood did not have the normal daily fluctuations in the stress hormone cortisol. They also had sudden surges in the hormone as soon as they were woken up, which can be a good stressor. People who had been sexually abused also had this odd cortisol response on being awakened. These findings suggest that severe traumatic experiences in childhood may be a factor in causing hormonal disturbances in people suffering from fibromyalgia. This adds to the growing body of evidence that in women having pain early in the day, there is a high likelihood that the entire stress hormone system does not function normally.

Colleagues from the Department of Psychiatry, UMDNJ-New Jersey Medical School in Newark, New Jersey have reported that women who have been raped are ten times more likely to experience chronic pelvic pain as well as generalized pain.

Another study has found close correlations between childhood abuse and the subsequent development of chronic pain. The link between rape and the subsequent development of fibromyalgia seems to be mediated by chronic stress, in the form of posttraumatic stress disorder.

What this means is that professionals need to consider this:

  1. It is important careful to inquire about any history of past or present abuse or other severe trauma
  2. That empathy and constructive validation of disease and suffering can be very helpful
  3. That dysfunctional pain behaviors and personality traits may be a consequence of abuse together with a lack of resilience
  4. That multidisciplinary treatments including psychotherapy may be the best approach to helping people. Using the methods of Integrated Medicine is often far better than reliance on potentially habit-forming medications.

If we remember that there is more and more evidence of inflammation and other physical problems in fibromyalgia, and that stress and maltreatment in early life can alter the structure and function of specific regions of the brain, what this all shows us is that abuse in childhood can have a long term impact on the way in which both the body and the brain functions.

Irritable Bowel Syndrome, Mood Disorders, the Serotonin Transporter and Integrated Medicine

Whenever we run into two common conditions, it’s easy to imagine links where none really exists. Three years ago some colleagues from Oxford reported on a person with bipolar disorder and irritable bowel syndrome, and commented that the association was uncommon.

However there may after all be a genuine link between mood disorders and irritable bowel syndrome, that is a disturbance in the “third arm” of the autonomic nervous system. The first arm is the sympathetic nervous system, the second the parasympathetic and the third is the enteric or gut nervous system that is closely linked with key regions of the brain.

Not long ago there was an interesting report of a woman who had multiple problems including environmental allergies, atypical bipolar disorder, irritable bowel syndrome and Raynaud’s phenomenon. Such odd constellations of problems are quite familiar to anyone working in the major referral centers around the world, and some can be exceedingly hard to treat. Tough cases like this often stimulate further research. I once tried and failed to treat a woman with a chronic illness. When she came back a year later to see if I had any new ideas, I told her that I now had a shelf of books and over a thousand reprint of papers about her condition: I don’t like failing someone. And I’m not unique in that.

A new study from the Karolinska Institute in Stockholm, has found that chronic widespread pain, which, as I explained recently, is the cardinal symptom of fibromyalgia, is prevalent and co-occurs with other symptom-based conditions such as chronic fatigue syndrome, joint pain, headache, irritable bowel syndrome, and psychiatric disorders.

There is more and more evidence of a link between fibromyalgia, irritable bowel syndrome and depression. It is not just that people are sick and get depressed: as we shall see in a moment, the link is more subtle than that. Another illness seemingly linked to these three is interstitial cystitis.

Now some colleagues at the National Institutes of Health have been looking at a serotonin transporter (SERT) that regulates the entire serotoninergic system and its receptors. This transporter is found throughout the animal kingdom, telling us that it must be important.

In humans the gene is located on chromosome 17, and disturbances in it have been found in people with autism, ADHD, Tourette’s syndrome and bipolar disorder. Experiments using genetic engineering suggest that SERT may be a candidate gene for several human disorders, from obesity to irritable bowel syndrome. People who have disturbances in SERT tend not to respond so well to the serotonin reuptake inhibitors (SSRI’s) antidepressant medicines.

SERT is not the whole story. Some geneticists from Los Angeles have found evidence linking irritable bowel syndrome, depression, migraine and inheritance of mitochondrial DNA.

Many approaches have been tried to help people with these groups of problems. I always find it remarkable that psychological treatments can be so effective in conditions with a genetic component, for this once again proves that biology is not destiny.

The best approaches to conditions like irritable bowel syndrome and coexisting mood disorders is to use medications and psychological approaches. Many of us have also found that the addition of nutritional, environmental and subtle energetic approaches have been of great help, together with some work to uncover the meaning and transpersonal value of a chronic illness. That last piece is not the first priority, which is to help the person gain control of his or her life. But if we don’t do something to work with the meaning and purpose of an illness, it will usually come back in some form or other. This comprehensive approach differentiates Integrated Medicine from many other types of therapy.

Chronic Widespread Pain, Fibromyalgia and Anti-inflammatory Proteins

Chronic widespread pain is a common and distressing medical condition that can be difficult to treat and is usually associated with fatigue, poor sleep and depression. One major subgroup is fibromyalgia. A connection between fibromyalgia and cytokines – small proteins that act as messengers between cells – has been suspected for some time, since some cancer patients treated with the cytokine interleukin -2 develop fibromyalgia-like symptoms. A new study from Wurzburg in Germany, published in the August 2006 issue of Arthritis and Rheumatism examined cytokine profiles in patients with chronic widespread pain and found that they had significantly lower levels of the anti-inflammatory cytokines IL-4 and IL-10.

This is an important finding: Previous research has shown that IL-10, administered as a protein or via gene transfer, reduces sensitivity to pain. Similarly, IL-4 has been shown to dull the pain response. There is also another piece to this: genetic variations in different cytokine genes are associated with distinct diseases, such as the association between IL-4 gene variations and asthma, Crohn’s disease, and chronic polyarthritis.

Although low levels of anti-inflammatory cytokines could be a consequence of chronic widespread pain and its treatment, it is much more likely that these proteins actually play a role in the causation of chronic widespread pain.

This new research raises all kinds of possibilities for the physical treatment of a particularly horrible set of illnesses.

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