Migraine in Men Not Uncommon but Not Always Diagnosed


It is not uncommon for men to suffer migraines, but they are less likely than women with this condition to consult a doctor, and if they do, they are less likely to be diagnosed with migraine.

Those are some of the conclusions of a study on sex differences in migraine burden presented at the American Headache Society (AHS) 58th Annual Scientific Meeting.

“While migraine is more common in women than in men, it does afflict 6% of American men,” said Richard Lipton, MD, professor and vice chair of neurology, Albert Einstein College of Medicine, and director, Montefiore Headache Center, New York City.

“The myth that migraine is a women’s disease may contribute to the stigma of migraine and certainly denies men access to medical care.”
Dr Richard Lipton
Dr Lipton reminded physicians that migraine is “very common in men” and that men may be reluctant to talk about their headaches.

For this Chronic Migraine Epidemiology and Outcomes (CaMEO) study, participants with migraine completed a baseline survey and a second online survey 3 months later.
Researchers assessed sociodemographic information; headache features; headache-related disability, using the Migraine Disability Assessment Scale (MIDAS); symptom severity, as measured by the Migraine Symptom Severity Score; cutaneous allodynia, using the Allodynia Symptoms Checklist; and treatments.

Of the 16,789 respondents, 25.6% were men. The mean age of respondents was 42.0 years for men and 40.8 years for women.

The men reported fewer headache days per month than women (4.3 vs 5.3; P < .001).

MIDAS scores were generally lower in men (P < .001). Whereas 24.1% of women were in the highest MIDAS category, only 15.7% of men were in this category.

Higher MIDAS scores among women suggest that their migraines have a more severe impact on their daily life in areas such as time lost from work or school and social and leisure activities.

Sex hormones contribute to the increased incidence and severity of migraine in women, Dr Lipton noted.

“The risk of migraine in women increases with sexual maturation,” he said, adding that there may also be sex differences in symptom reporting.

Interestingly, migraine is more common in boys than girls before puberty. The risk “takes off” in women after the onset of the menstrual cycle, said Dr Lipton.

“But our major points are that migraine is common in men even though it is more common in women and that it is severe in men even though it is more severe in women.”

Significantly fewer men than women in the study reported allodynia (32.6% vs 49.7%; P < .001). Allodynia is defined as experiencing typically nonpainful stimuli ― for example, wearing a hat or laying your head on a pillow ― as painful during a migraine.

“Allodynia develops as a response to attack frequency and severity and is one of the pieces of evidence that migraine is worse in women,” commented Dr Lipton.

Men were less likely than women to report seeing a physician to manage their headaches (28.6% vs 31.1%; P < 0.01).

Although men generally seek medical care less often than women for a range of conditions, in the case of headaches, “the myth that migraine is a women’s disease may make men with migraine more reluctant to seek care,” said Dr Lipton.

If men in the study did consult a physician, they were less likely than women to receive a migraine diagnosis (59.2% vs 77.7%; P < .001), suggesting that migraine is underdiagnosed in men, said Dr Lipton.

As for treatment, 24.1% of men and 28.2% of women reported using prescription medications to treat headaches (P < .001). Men and women used prescription preventive treatments in a similar manner.

Benjamin W. Friedman, MD, associate professor of emergency medicine, Albert Einstein College of Medicine, who is a colleague of Dr Lipton’s but was not involved in the current study, commented on the findings for Medscape Medical News.

“It is interesting that there were both patient-related reasons (lower levels of consulting) and physician-related reasons (failure to diagnose) for men obtaining appropriate treatment for migraine less frequently,” Dr Friedman noted.

“Men do seem to experience migraine differently than women. This is reflected elsewhere in the medical literature,” he added. “Epidemiologically, even though men experience migraine less frequently than women, this is still a highly prevalent illness that affects hundreds of millions of men worldwide.”

Continuous L-Dopa Enteric Infusion Relieves RLS Symptoms


Patients with restless legs syndrome (RLS) for whom conventional therapies are contraindicated may benefit from a treatment usually reserved for patients with advanced Parkinson’s disease and augmentation phenomena, a case report suggests.

In a presentation here at the 20th International Conference of Parkinson’s Disease and Movement Disorders, Jesús Pérez-Pérez, MD, of the Movement Disorders Unit at the Hospital de la Santa Creu i Sant Pau, in Barcelona, Spain, described the case of a 70-year-old man who had experienced RLS with augmentation for 3 years. The patient was successfully treated using a 24-hour infusion of carbidopa/levodopa enteral gel (Duopa, AbbVie Inc).

His condition had initially responded well to dopaminergic medication, but after 1 year of therapy with dopaminergic drugs, augmentation began, and RLS was present all day and was worse at night. Augmentation is a phenomenon of worsening symptoms after dopaminergic drug exposure.

The patient had severe, chronic obstructive pulmonary disease and had undergone several hospitalizations in less than a year because of respiratory decompensation. For these reasons, drugs such as benzodiazepines, opioids, gabapentin (multiple brands), and pregabalin (Lyrica, PF Prism CV) were contraindicated. Because of RLS, the patient was unable to use nocturnal continuous positive airway pressure, which led to hypercapnic respiratory failure.

The treating physicians then offered, and the patient accepted, 24-hour constant infusion with carbidopa/levodopa enteral gel delivered by pump directly into the small intestine through a tube with a jejunal extension introduced percutaneously into the stomach. Because of the continuous drug delivery, this system avoids the pulsatile dosing effect that leads to augmentation.

Three months after starting therapy with the enteral gel formulation, the patient’s RLS symptoms were greatly improved, as was his quality of life, Dr Pérez-Pérez reported.

Table. Results of Switching Patient From Oral to Enteral Infusion Medication

Intervention/Period RLS Rating Scale Score RLS Quality-of-Life Questionnaire
Oral/preintervention* 36 (very severe) 22
Enteric gel at 3 months 9 (mild) 74
Enteric gel at 1 year 4 (mild) 100
*Levodopa/carbidopa 150 mg 5x/day plus levodopa/carbidopa retard 200 mg at night.

Symptoms and quality-of-life scores continued to improve during the first year of treatment, as reflected in Clinical Global Impression–Improvement scale scores.
The patient has not experienced any adverse effects or complications from the medication or the implantation procedure and was hospitalized only once during the year.

Olga Klepitskaya, MD, associate professor of neurology at the University of Colorado, in Denver, who has a special interest in the use of deep brain stimulation to treat RLS, commented to Medscape Medical News that although the presentation involved a single case report, it was well done and is important. “They described very well why they did [it] and what they did and what are the implications of that,” she said.

“Just like in Parkinson’s disease, with RLS…pulsatile dopaminergic stimulation is not healthy for our dopamine receptors in the brain, and that’s why it causes all these problems of augmentation,” she said. The mainstream treatment of augmentation is to use longer-acting dopaminergic medications, such as rotigotine transdermal patches (Neupro, UCB Pharma, Inc), longer-acting pramipexole (Miraprex ER, Boehringer Ingelheim Pharmaceuticals, Inc), and ropinirole (Requip XL, GlaxoSmithKline).

The treatments that provide constant dopaminergic stimulation are better physiologically for the brain, “and Duopa is the ultimate long-acting medication,” she said. “It’s administered through the GI system, and I assume it can be used for very, very severe RLS with augmentation that cannot be treated by anything else.”

Calling delivery of the medication through a percutaneous indwelling tube “a little bit extreme,” she said the authors “really justified why they used this…for this particular patient, because he had a lot of comorbidities that can [lead to] a lot of side effects.”

For this patient, the choice of this continuous but somewhat invasive treatment, which led to significant improvement in quality of life, appeared correct, she said.

Dr Klepitskaya said she believes that treatments that provide continuous stimulation ― whether pharmacologic or electrical ― would be best.

“That’s why I have put my hopes in my study, deep brain stimulation for RLS,” she said, “and deep brain stimulation and Duopa now can be not completely interchangeable, but we are considering both as treatments available in the United States in patients with very advanced Parkinson’s disease and trying to find which of those treatments will fit that particular patient profile the best.”

The current case report and other reports on the use of deep brain stimulation suggest that difficult-to-treat RLS may be amendable to these treatments as well.

CRP Levels Elevated in Migraine


Levels of the inflammatory marker C-reactive protein (CRP) are significantly elevated in young adults with migraine, which may not only offer insights into the pathogenesis of the condition but also point to novel therapeutic avenues, researchers say.

Delegates here at the American Headache Society (AHS) 58th Annual Scientific Meeting heard that levels of the protein, as measured on high-sensitivity CRP (hsCRP) assay, were higher by 11% in people with migraine compared with those in unaffected individuals, rising to 17% among women.

Gretchen Tietjen, MD, professor and chair of neurology and director of UTMC Headache Treatment and Research Program, University of Toledo, Ohio, and colleagues say the study findings show “a positive association between migraine diagnosis and elevated hsCRP, with a significant effect size,” particularly in young women.

Conflicting Results

Although there has been a great deal of interest in potential association between markers of inflammation and migraine, the evidence linking increased CRP levels with the condition is limited, and there have been conflicting results from population-based studies. However, it is notable that those studies were conducted in different age groups from that in the current analysis.

The researchers therefore examined data on 9269 adults aged 24 to 32 years taking part in Wave 4 of the Add Health Study, as part of which participants discussed diagnoses of migraine, depression, and anxiety with their healthcare provider. In addition, dried capillary whole blood spots were obtained from the individuals during in-home visits, on which blood hsCRP assay was performed.

The team found that 1049 (11.3%) participants reported migraine.

Linear regression analysis, taking into account sociodemographic factors, body mass index, infections, current pregnancies, subclinical symptoms, anxiety, and depression, indicated that mean hsCRP levels were significantly higher in individuals with migraine than in those without.

Specifically, participants with migraine had an hsCRP level of 5.54 ± 9.04 mg/L vs 4.40 ± 7.47 mg/L in those without migraine (P < .001).

Although women had higher mean hsCRP levels than men, the difference in levels between those with and without migraine was significantly different only in men, at 3.63 ± 6.32 mg/L vs 3.05 ± 5.25 mg/L in men (P = .03) and 6.26 ± 9.78 mg/L vs 5.75 ± 8.97 mg/L in women (P = .08).
Interestingly, when all potential confounding factors were taken into account, migraine was significantly associated with log hsCRP levels across the whole sample, at an r value of 0.11 (P = .04), and in women, at an r value of 0.17 (P = .01), but not in men (r = 0.01; P = .94).

Dr Tietjen believes that the relationship between CRP levels and migraine could be direct. “I think that it is possible that it is a consequence of having migraine, in that, when there’s changes within the brain in the endothelium, that can increase levels of things like [CRP] and inflammation,” she said.

Noting that the relationship was more pronounced in women, she added: “Whether it has something to do with endothelial activation being more easily triggered in women than in men I think is interesting, but I don’t think we can say for sure why we would see it more frequently in women than men.”

Nevertheless, Dr Tietjen said the current findings may point to therapies that target inflammation in general, and CRP levels in particular, potentially being beneficial in migraine.

She highlighted the JUPITER trial, in which the statin rosuvastatin was shown to reduce the incidence of major cardiovascular events in individuals with high CRP levels, although she acknowledged that concerns have been raised about the study’s methodology.

In addition, Catherine Buettner MD, MPH, and colleagues conducted a randomized, double-blind, placebo-controlled trial of simvastatin plus vitamin D, finding that the combination is effective for prevention of headache in adults with episodic migraine.

“Why would it be an effective migraine treatment unless something tied into the migraine pathogenesis had either something to do with cholesterol or inflammation or something that statins actually work on?” Dr Tietjen commented.

“I did think that that was very intriguing, as [CRP] might be something that would guide us as to which patients would be most likely to respond to which therapies,” she added.

Dr Tietjen concluded: “I think it’s an area ripe for more study, but I do believe that it makes sense in what we’re learning both about the importance of the endothelium potentially in migraine and the fact that we are seeing that some therapies that actually have an effect on [CRP] may be effective in migraine in a relatively young, healthy population of people.”

Commenting on these findings, Stephen Silberstein, MD, professor, Department of Neurology, Thomas Jefferson University and Jefferson Health, and director, Jefferson Headache Center, Department of Neurology, Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, said the results “look interesting.”

However, he told Medscape Medical News that the wide overlap in the confidence intervals were “of concern” and limited the degree to which the study could be interpreted.

How the Brexit Decision Might Affect Healthcare


The world is reeling from the United Kingdom’s (UK) historic vote on Thursday to leave the European Union (EU). The ramifications will be felt in all aspects of life, from economic, to travel and immigration, to national security, and not the least, to health.

The future of the UK’s National Health Service (NHS) featured prominently in the run-up to yesterday’s referendum, and will figure prominently in the changes brought about by the decision.

 While the “Leave” camp claimed the cash that the UK currently gives to the central leadership of the EU in Brussels, Belgium could now be ploughed back into health services, the “Remain” camp warned that economic turmoil from the British Exit (Brexit) threatened the fragile finances of the NHS.

But the bell has been rung. Now that 51.9% of the UK’s citizens chose to get out of the EU, while 48.1% backed remaining part of the club of 28 nations, what might the impending exit mean for the future of health and social care in the UK?

Timing

Firstly, nothing significant is going to change today or tomorrow.

Soon after the result was declared, Prime Minister David Cameron announced he would stand down in the autumn, by which time another member of the conservative party will be chosen to be the new leader in the UK.

 It will be up to the next prime minister to decide when to pull the lever to leave the EU, known as Article 50 of the Lisbon Treaty, which would give the UK 2 years to negotiate withdrawal terms.

Will There Be More Cash for the NHS?

Supporters of Leave originally claimed that quitting the EU would give the UK an additional £350 million a week to spend on health and other public services.

 However, an analysis this month by the Institute for Fiscal Studies (IFS) disputed this figure, saying that after taking into account money received back from the EU, the UK’s net contribution was £150 million a week.

However, this takes no account of any financial turmoil that could hit government finances.

The IFS analysis predicted that Brexit will add an additional 2 years of austerity to the UK’s economy. Carl Emmerson, IFS deputy director and an author of the report, said: “the overwhelming weight of analysis suggests that the economy would shrink by more than enough to offset the positive effect on the public finances of the reduced financial contribution to the EU budget.”

Will Containing Immigration Cut NHS Costs?

Immigration and its effect on health and other public services was a key topic during the referendum campaign.

 A recent analysis by the Nuffield Trust estimated that in 2014, migration from the EU added £160 million in additional costs for the NHS across the UK.

However, it says this was a relatively small sum when set against the £1.4 billion in additional costs caused by other factors such as treating an ageing population and migrants from outside the EU.

The report also pointed out that immigrants are taxpayers as well as patients and that they could even be making a net contribution to available resources.

Will Health Insurance Cards Still Work in the EU?

British travellers to EU and European Economic Area (EEA) countries can carry a European Health Insurance Card (EHIC) giving them the right to access state-provided healthcare on temporary stays at a reduced cost or, in many cases, for free.

 But once the UK leaves the EU, and if it also left the EEA, British tourists and retirees abroad would have to cover health care costs from their own pockets or from travel insurance in these countries.

However, it is possible that the UK could negotiate specific agreements with EU and EEA countries for EHIC to remain valid.

What About the NHS Staff?

A total of 55,000 out of the 1.2 million staff in the NHS in England are citizens of other EU countries — equivalent to 5% of NHS workers.

That is close to the 4.7% of the UK population who were born in other EU countries.

According to the Nuffield Trust, 10% of physicians and 4% of nurses are from other EU countries.

The NHS’s most senior physician, Sir Bruce Keogh, MD, has called on NHS leaders to send out a message to European staff working in the health service that they are valued and welcome in the wake of the referendum result. Sir Bruce told the Health Service Journal: “It is really important we make them feel welcome.

“If you are a European doctor or nurse you might not feel too welcome at the moment.”

The British Medical Association (BMA) urged politicians not to play games with the UK’s health services. BMA council chief, Mark Porter, MD, said in a statement: “We stand together as one profession with our colleagues from Europe and across the world, with whom we live, work and study and on whom the NHS depends.”

What About Medical Research?

UK medical science has benefited from EU funding for decades.

In the wake of the result, several leading experts issued statements about what it could mean for research.

 Nobel Laureate Sir Paul Nurse, PhD, director of the Francis Crick Institute, said: “This is a poor outcome for British science and so is bad for Britain.

“Science thrives on the permeability of ideas and people, and flourishes in environments that pool intelligence, minimise barriers, and are open to free exchange and collaboration.

“British scientists will have to work hard in the future to counter the isolationism of BREXIT if our science is to continue to thrive.”

 Professor Anne Glover, PhD, vice-principal external affairs and dean for Europe at the University of Aberdeen, said: “I am personally heartbroken and I have great concern for the future of British science, engineering and technology.

“Our success in research and resulting impact relies heavily on our ability to be a full part of European Union science arrangements and it is hard to see how they can be maintained upon a Brexit.”

Could the Exit Affect Access to Medicines?

Leading figures from the life sciences industry recently expressed their fears that Brexit could jeopardise the UK’s central role in the European pharmaceutical industry and call into question the country’s access to innovative medicines.

 Following the result, Mike Thompson, the head of the Association of the British Pharmaceutical Industry (ABPI), said in a news releases that leaving the EU would create “immediate challenges for future investment, research and jobs in our industry in the UK.”

Meanwhile, the BioIndustry Association (BIA) said in a statement that “key questions about the regulation of medicine, access to the single market and talent, intellectual property and the precise nature of the future relationship of the UK are now upon us.”

Before the vote, the ABPI, BIA, and business leaders and organizations for the life-sciences industry, had signed a letter warning that the UK leaving the EU would put access to cutting-edge medicines at risk, according to the ABPI release.

 An early sign of the threat posed to the UK’s position came as the association representing Germany’s pharmaceutical industry, Beraten Analysieren Handeln, called for the European Medicines Agency (EMA), the UK’s equivalent to the US Food and Drug Administration, to be relocated from its central seat in London to Bonn, Germany following the UK’s departure from the EU.

8 Signs You’re Eating Too Much Sugar


Sugar is delicious. Anyone who denies that is lying. But because life is unfair, sugar, especially in copious amounts, is really bad for your health. In fact, once you learn about all the ways sugar impacts your body, it’s difficult to look at it the same way (despite knowing how heavenly it tastes).

So how do you know if you’re eating too much? Here are eight red flags your body is sending you that it’s time to cut back on the sweet stuff.

1. You constantly crave sugary things. The more sugar you eat, the more you’ll crave it. “More cravings then equal consuming more sugar—it becomes a vicious and addictive cycle,” Brooke Alpert, M.S., R.D., author of The Sugar Detox: Lose Weight, Feel Great and Look Years Younger, tells SELF. This isn’t just because your taste buds have adapted and left you needing more and more to get that same taste, but also because of how sugar gives you a high followed by a crash, just like an actual drug. “By eating a high sugar diet, you cause a hormonal response in your body that’s like a wave, it brings you up and then you crash down and it triggers your body to want more sugar.”

2. You feel sluggish throughout the day. What goes up must come down. After sugar causes an initial spike of insulin and that “high” feeling, it causes an inevitable crash. “Energy is most stable when blood sugar is stable, so when you’re consuming too much sugar, the highs and lows of your blood sugar lead to highs and lows of energy,” Alpert says. Eating a lot of sugar also means it’s likely you’re not eating enough protein and fiber, both important nutrients for sustained energy.

3. You’ve been putting on some weight. Excess sugar is excess calories, and since it has no protein or fiber, it doesn’t fill you up (so you just keep eating it). It also triggers the release of insulin, a hormone that plays a big role in weight gain. When we eat sugar, the pancreas releases insulin, which carries sugar to our organs so it can be used for energy. When you load up on sugar, your body’s told to produce more insulin—over time, that excessive output can lead to insulin resistance. Insulin resistance means our bodies can’t respond to normal amounts of insulin properly and therefore can’t use sugar the right way. The initial weight gain from simply eating too many calories from sugar is being compounded by the disruption to your normal insulin response (there’s a link between insulin resistance and obesity). What’s more, when the pancreas works in overdrive for too long you can develop diabetes.

Why does something that tastes so good have to be so bad for us?

4. Your skin won’t stop breaking out. “Some people are sensitive to getting a spike in insulin from sugar intake, which can set off a hormonal cascade that can lead to a breakout like acne or rosacea,” Rebecca Kazin, M.D., of the Washington Institute of Dermatologic Laser Surgery and the Johns Hopkins department of dermatology, tells SELF. A sugar binge can show up on your face in just a few days. If your skin’s unruly, Kazin recommends reassessing your diet, otherwise “you may be treating skin for other issues without getting to the bottom of what’s really going on.”

5. You’re way moodier than usual. The blood sugar crash that happens when you’re coming off a sugar high can cause mood swings and leave you feeling crabby. Not to mention, if your energy is also tanking, that just contributes to a bad attitude.

6. You’ve been getting more cavities. When bacteria chow down on food particles in between the teeth, acid is produced, which causes tooth decay. Our saliva maintains a healthy balance of bacteria on its own, but eating sugar can impact the pH and throw off the natural ecosystem. This gives the bacteria a chance to thrive and multiply, leading to cavities.

7. Your brain tends to get foggy, especially after a meal. This fog is a common symptom oflow blood sugar. When you eat a lot of sugar, your blood sugar levels rapidly rise and fall instead of gradually doing so. “Poor blood sugar control is a major risk for cognitive issues and impairment,” says Alpert.

8. Nothing tastes as sweet as it used to. “Eating too much sugar basically bombards your taste buds,” Alpert says. “This sugar overkill causes your taste bud sugar tolerance to go up, so you need more and more sugar to satisfy that sweet craving.” When your taste buds need lots of sugar to feel like something is sweet enough, it can be tough to lower your base level. However, it you cut back and suffer through it in the beginning, you’ll eventually lower your tolerance again and be content with minimal sugar. You might even start to feel like things are too sweet for you and—gasp!—be happier consuming sugar in moderation.