BOTOX TREATMENT FOR MIGRAINE

Botox Therapy for Chronic Migraine

What is migraine?

• Migraine is a condition, characterized by repeated episodes of headache.
• Headache can be on one side or both sides of head.
• Headache typically lasts for more than four hours, but usually resolves in less than 72 hours.
• Nausea (a sensation to vomit) or vomiting may be present during headache episodes.
• There may be photophobia (headache becomes more in bright light or sunlight) or phonophobia (headache becomes more in noise).

 What is chronic migraine?

A person, who has been suffering from migraine, for a period of more than six months, is said to be suffering from chronic migraine.

What is the impact of chronic migraine on the sufferer?

Chronic migraine leads to a number of problems in the sufferer:

• Recurrent headache interferes with job or studies, leading to poor performance at work or in studies.
• It leads to frequent absenteeism at workplace or in college.
• People suffering from chronic migraine can not enjoy social functions, as slight triggers such as music can trigger the headaches.
• They need to avoid road travel, as it can trigger headaches.
• Patients are frequently forced to take multiple analgesics (pain-killers) every month, leading to significant adverse effects.

What are the treatment options for patients with chronic migraine?

Patients with chronic migraine, who get three or more than three episodes of headache in a month, require preventive therapy (medications to prevent repeated episodes of headache).

What are the commonly used medications to prevent headaches in a migraine patient?

Following medicines (with their brand names) are available for use in chronic migraine:

Tablets

·        Amitryptiline (Tryptomer)

·        Flunarizine (Sibelium)

·        Propranolol (Betacap TR, Ciplar LA)

·        Divalproex (Divaa OD, Dicorate ER)

·        Topiramate (Topamac)

Injections

·        Botulinum toxin (Botox) injections

What are the disadvantages of oral medications?

1.      Lack of efficacy- many people do not adequately respond to these medications. They continue to get recurrent headaches despite taking them for long periods.

2.      Adverse effects- Significant adverse effects are noted with oral medications.

·        Amitryptiline- drowsiness

·        Flunarizine- drowsiness, weight gain

·        Propranolol- aggravation of asthma, depression

·        Divalproex- weight gain, tremors of hands, hair loss, pregnancy-related complications,

·        Topiramate- tingling of feet, weight loss, glaucoma in rare cases, renal stones in rare cases.

 3.      Need to take them on a daily basis

What are the advantages of Botox injections over oral medications in migraine treatment?

1.      Efficacy of botox in migraine has been proven in research and clinical practice.

2.      Botox is fairly safe and the side effects are negligible.

3.      Botox injections need to be repeated once in 3-6 months, so, the patient compliance is better and they can get rid of daily tablets.

Facts regarding Botox injections in a patient with migraine

·        There are fixed points over the scalp, where the injections are given (irrespective of the site of head pain).

·        These locations include front of head, over eyebrows, temple region, back of head and neck muscles.

·        Injections are given by a neurologist, who is trained in the botox procedure.

·        It is given by insulin syringe and needle, and is given in the superficial tissues (scalp muscles, which are hardly a few mm beneath the skin).

·        Topical (surface anesthetic) creams are used, so, the injection does not hurt much and is almost painless.

·        The whole procedure can be completed in an office (Outpatient) set up and is completed in 15-20 minutes.

·        Patient can leave for office or home immediately after the botox procedure.

·        A total dose of 155 units of botox is used in chronic migraine.

Are there any side effects of botox injections?

·        This is the same botox that is used in cosmetic procedures and several million patients have received botox for neurological problems as well (such as writer’s cramp, dystonia, blepharospasm, post-stroke spasticity, hyperhidrosis, etc).

·        It is among the safest injections, and has no serious side effects.

·        Mild pain at the injection site may be felt (just as is felt with any injections).

·        Mild bruising (and redness) and swelling may occur at the injection site.

·        Mild eyelid droop may occur, which improves in a few days on its own.

My experience with Botox in migraine

• I see about 15-20 new cases of migraine per month, and have seen thousands of patients in the past 18 years of my medical practice.
• About 20-30% of them either do not improve with oral preventive tablets or they have side effects with them. Some people find it difficult to take tablets on a daily basis for a long period of time.
• For this group of patients, botox injection therapy is the most ideal. I see 2-3 patients per month, who are eligible to receive botox therapy in chronic migraine. About 1-2 per month receive them. In the past two years, I have given botox to about 40 patients with chronic migraine.
• About 95% patients report benefit after botox therapy and in most cases, oral tablets are not required after botox.
• None of them reported any adverse or side effects with botox.

I would like to share an interesting experience with one of the patients. Mrs Nazia (name changed) from Dubai came in June 2012 for botox therapy in migraine. I gave her the injections on OP basis on the usual sites, including forehead. She had no side effects with botox. She came back for review three months later and reported that she was totally headache-free. However, she wanted a repeat botox injection. I was surprised. I asked her if she has no headache, then why does she want botox! She said, after botox, her husband has started to give her more attention and love, as her face has also improved (then, I realized that she wanted it for cosmetic effects). She also told me that three of her colleagues at her office want the botox to be given by me (but only for cosmetic reasons). I had a tough time, referring them to a cosmetic surgeon for the same.

If you want any further information regarding botox therapy in migraine, please email me at drsudhirkumar@yahoo.com

Dr Sudhir Kumar MD (Medicine) DM (Neurology)

Senior Consultant Neurologist

Apollo Hospitals, Jubilee Hills, Hyderabad

Email: drsudhirkumar@yahoo.com

Phone-0091-40-23607777/60601066

IVIG (Immunoglobulin) THERAPY IN NEUROLOGY

IVIG THERAPY IN NEUROLOGY

Introduction

Neurology is one area, where we see patients who are critically ill, and require emergent and aggressive medical care for better outcomes. This branch of Neurology is also called NEURO CRITICAL CARE. I have a lot of passion for neuro critical care. Here, time is crucial. One has to make the diagnostic and treatment plans as fast as possible, so as to start the best treatment at the earliest, and I love that.

IVIG (INTRAVENOUS IMMUNOGLOBULINS)

IVIG belongs to the group of medicines, called as immunotherapy. This is used in illnesses, which are due to involvement of immune system. In many conditions, antibodies are produced in the body, which can harm, leading to diseases. In these diseases, IVIG treatment can be life-saving.

IVIG Treatment in Neurology

IVIG is required in the following neurological diseases:

1. Guillain Barre syndrome (GBS)- In this illness, patients have paralysis of both hands and legs and may get difficulty in breathnig also.

2. Myasthenia Gravis- In this condition, patients have drooping of eyelids, difficulty in speaking and swallowing, weakness of hands and legs and breathing problem.

3. Multiple sclerosis (MS)- In severe cases of MS, IVIG is useful.

4. CIDP- Chronic inflammatory demyelinating Polyradiculoneuropathy- In this condition, there is weakness of both legs and hands. When steroids do not work, IVIG may be required.

5. Epilepsy- In certain cases of epilepsy, such as West syndrome (seen in children), refractory status epilepticus (where fits do not respond to usual treatment), etc, IVIG therapy can be life-saving.


My Experience with IVIG Therapy

I have been using IVIG since 1995 (about 17 years now). I have given IVIG in all the above-mentioned indications and my experience with this medicine has been very good.
I remember several patients who came in states of severe disability and they recovered well.

One case, I would like to share with you. There was a young 25-year-old software professional Ms Reena (name changed) from Chennai, who had developed severe GBS. She rapidly worsened, became totally paralysed in whole body, and could not breathe. She was put on ventilatory support for the same. As she was not responding to the treatment, their family consulted me. I advised them to shift her to Apollo Hyderabad under my care. She was treated with a course of IVIG, ably supported by our excellent ICU doctors and nurses. She showed gradual improvement and was discharged from hospital after one month. She had little movements of hands and legs at discharge, could not speak, and required feeding through a nasal tube. I advised them to continue physiotherapy. She came back after two months to my OPD for a review. I was pleasantly surprised to see her totally normal. When I asked her if she had any problem, she replied- "yes- my nails have become dark, what to do to make them better?" I could not stop smiling to see the extent of recovery.

There are several similar cases that come to mind, when I look back at more than 500 patients during the past 17 years, who were treated with IVIG under my care and showed excellent recovery.

Dose of IVIG

The standard dose of IVIG is 0.4 grams per kg body weight per day for five days (a total of 2 grams per kg body weight). For ex- a person with body weight of 75 kg would require 150 gms total dose of IVIG (30 grams per day for five days).

It is given as drip (infusion) in the hand veins, slowly over 4-6 hours (just how we give glucose or saline drip).

Cost of IVIG

IVIG is costly, as it is prepared from the plasma (a part of blood) of healthy volunteers. As the source of healthy plasma is scarce, IVIG also is scarce product. A typical vial of 5 gm would cost Rs 15000-20,000/ (USD 300-400). So, a person requiring 150 grams may need to spend Rs 4,50,000-Rs 6,00,000 (USD 9000-12000).

Side effects of IVIG

IVIG is fairly safe product. In some cases, minor allergic reactions may occur. This can include fever, chills, etc. This can be well managed with simple medicines and decreasing the rate of IVIG infusion.

If you require any further information about IVIG treatment, please send an email to me- drsudhirkumar@yahoo.com

Dr Sudhir Kumar MD (Internal Medicine) DM (Neurology)
Senior Consultant Neurologist
Apollo Health City, Jubilee Hills, Hyderabad
Phone- 0091-40-23607777/60601066
email: drsudhirkumar@yahoo.com

STRESS AND MEMORY LOSS

STRESS AND MEMORY LOSS

Dr Sudhir Kumar MD (Internal Medicine), DM (Neurology)

Senior Consultant Neurologist

Apollo Health City, Hyderabad

Introduction

Memory is one of the most important functions of human brain. A good memory is important in all stages of life. A child’s learning ability and scholastic performance depends a lot on his memory. Similarly, in adults, a good memory is vital to perform the job well. Normal memory is also required in day-to-day life activities. For example- a housewife depends on her memory of recipes to prepare a good meal. After having seen the importance of memory in our lives, it is easy to appreciate the hardships one would go through if there is memory loss. Memory loss, along with impairment of other brain functions, is also referred to as dementia.

Causes of memory loss

Memory loss occurs due to a dysfunction in brain. The commonest causes of memory loss are:

1. Alzheimer’s disease (AD): AD is the most common cause of dementia in the world. It is a degenerative disease of the brain and commonly affects older people.
2. Brain strokes- Strokes occur due to a lack of blood supply to the brain. These occur in people with risk factors such as smoking, diabetes, high BP and high cholesterol.
3. Infections- such as HIV, syphilis, brain fever (meningitis, encephalitis)
4. Nutritional deficiencies- such as vitamin B12 deficiency
5. Endocrine disorders- such as hypothyroidism (lack of thyroid hormone)
6. Head injury
7. Brain tumors
8. Stress and depression.

Stress and memory loss

Mental stress, anxiety, depression and other psychiatric disorders are important causes of memory loss today. In anxiety and stress, there is no structural damage of the brain (as compared to AD or brain strokes, where structural damage occurs). Therefore, a bran scan (CT or MRI) is often normal in stress-related memory loss; however specific findings on MRI brain occur patients with AD and brain strokes.  

Biochemical basis of stress-related memory loss

Stress or anxiety leads to several biochemical changes in the brain. During periods of stress, chemicals like adrenaline and cortisol are released. Adrenaline prepares an individual for “fight or flight response”, typically seen during acute stress/anxiety. Adrenaline promotes the release of cortisol. Both adrenaline and cortisol can adversely affect the memory. The major difference between the two is that cortisol stays in the blood and brain for a longer time than adrenaline. The effect of adrenaline is so powerful that our brain gets fogged out for some time during stress. You could see an individual looking blank and staring into vacuum. Only when the levels of adrenaline drop after stress is reduced does he come back to reality. So, one can imagine that if a person is under chronic stress and thus under the chronic influence of adrenaline and cortisol, it can lead to dysfunction and/or damage to brain. Cortisol is known to cause damage of hippocampus (the seat of memory in brain). An excess of cortisol can impair the hippocampus in such a way that one is unable to form a new memory, and not able to retrieve any existing information too.

            Here, one should remember that not all stress is bad for brain. Small periods of stress (such as stress of getting the project completed within the stipulated deadlines) could have a beneficial effect on brain functions. These brief stressful stimuli could keep the brain in an aroused state for sometime, thereby increasing its efficiency. So, the key is not to completely eliminate the stress but to ensure that it is brief. One should constantly practice means to reduce stress levels such as with practising yoga and meditation.

Effect of stress related memory loss

Chronic stress and subsequent memory loss not only affects the individual who is suffering, but it also impacts the life of immediate circle of relationships. For example, the person is unable to fulfill the roles of a father/mother or husband/wife. The person is irritable, which could further increase on forgetting important things. The person loses interest in sex and other pleasurable activities. This can lead to marital discord, sometimes resulting in divorce/separation. At work too, the person lags behind and is unable to complete tasks on time. Important assignments may be forgotten leading to serious problems for the organization. Affected persons may lose the job.

How can the immediate circle of people help the affected individual?

First of all, it is important to recognize that the person is suffering from stress and stress-related memory loss. Family and friends would be the first ones to notice any deviation from normal in the individual. If a person is found looking lost, or having a worried look all the time or taking longer time to complete simple tasks, one should suspect stress-related memory loss. It may be important to discuss the issue with close family members so that the reasons for stress can be identified. Common stressors include exams/studies, peer pressure, fear of getting reprimanded by the teacher/parents (in children) and interpersonal problems, job-related stress and marital discord (in adults). The affected person should be taken to a psychiatrist/neurologist for evaluation and proper diagnosis.

Differences between memory loss arising from shock and long-term mental trauma

Effects of acute stress or shock on memory differ from that of the long-term stressful events. Acute stress or shock is a sudden onset brief event and the physiological changes are not ongoing, whereas in long-term stress, the physiological changes persist for longer duration. Acute stress can have mixed effects on memory. Some studies report better memory after a brief stress. However, for this to happen, the context for stress and desired memory should be regarding the same topic. Shock also has a specific influence on memory. Most people are not able to recall the events that happened just prior to the shock; however, they are able to remember the place/details regarding the shock itself.

            Long-term stress has more negative influence on memory. Children who are victims of abuse or bullying have difficulty in learning and they perform poorly at school. This effect may persist in their adulthood too. People subjected to chronic stress also find it difficult to adapt to new situations.

Manifestations of stress-induced memory loss in children and adults

The pattern of stress-induced memory loss differs in children from that of adults. In infants and children, the brain is not fully developed and hence any effect of stress can have long-lasting effects. Studies have shown that children who experienced prolonged stress during infancy/early childhood developed memory loss and cognitive difficulties starting in middle age (similar to that occurring in very elderly). In adults, stress mainly affects new learning ability and working memory; however the long-term memory may remain relatively spared.

Is stress-induced memory loss temporary or permanent?

This depends on the type of stress and duration of stress. Typically, after a short-term stress, memory loss is mild and temporary and one can expect a complete improvement. However, after long-term stress, memory can be chronically impaired. This is because, prolonged presence of cortisol (as seen with prolonged stress) can cause severe damage to the hippocampus and prefrontal cortex, brain parts most essential for good memory functions.

Conclusions

Stress in addition to causing diseases like high BP, headaches, and increasing the risks of heart attack and brain stroke, has detrimental effects on memory too. The negative effects on memory of chronic stress are more severe that of acute stress. Memory loss is mediated by the effects of negative effects of prolonged cortisol exposure on hippocampus. Memory loss due to stress can occur at all ages, somewhat more severe in children. Therefore, every attempt should be made to reduce the stress, and prevent it from becoming chronic.

(Note: This article was first published in B Positive magazine, May 2012 issue)

DR SUDHIR KUMAR MD (Medicine), DM (Neurology)
Senior Consultant Neurologist
Apollo Hospitals, Hyderabad
Phone: 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com

TRIGEMINAL NEURALGIA

TRIGEMINAL NEURALGIA

Recently after the famous Bollywood star (Salman Khan) was referred for surgery for trigeminal neuralgia, there is a lot of interest in this condition.

What is trigeminal neuralgia?

Trigeminal neuralgia (TN), also referred to as suicide disease, is a condition characterized by intermittent severe, sharp, shooting pain usually affecting one side of the face (the area over face, which is supplied by the fifth cranial nerve, also called the trigeminal nerve). Facial sensations such as hot or cold temperature, touch and pain are transmitted from face to the brain, via the trigeminal nerve. The nerve is called trigeminal nerve, as it has three branches supplying sensations over the upper, middle and lower thirds of the face, respectively.

How common is trigeminal neuralgia and who are affected by it?

TN is an uncommon condition, affecting 155 per million population. Male to female ratio is 2:3 (it is more common in females). TN mostly occurs after age 50, but it may affect people in 25-50 age group also. In younger patients, multiple sclerosis is a common cause of TN. Children are usually not affected by TN.

What are the clinical features of TN?

·         Patients suffering from TN usually complain of severe, sharp, shooting pain affecting one side of face. Pain is usually located in the middle and lower thirds of the face, and the upper one third is uncommonly affected.

·         Pain may also occur in the lips, gums, teeth, eye, ear, forehead or cheeks.

·         It is described as a lancinating pain or as an electric-shock like sensation.

·         Pain often affects only one side of face, however, in some cases (about 10% of those affected); pain may involve both sides of face.

·         Pain is of short duration, often lasting for a few seconds and rarely lasting for more than 1-2 minutes.

·         Pain recurs several times in a week and sometimes several times in a day.

·         Patients are often normal in between the pain attacks.

·         There may be relative periods of improvement lasting for a few months.

·         Facial pain gets aggravated by simple activities like brushing teeth, washing face, chewing food, shaving and sometimes by light breeze/air from fan or AC.

·         Trigeminal neuralgia, if left untreated, may become chronic and persist for several years.

·         Pain in TN is often severe and repetitive, thereby, hampering the activities of daily living. Many patients have problems performing their daily jobs due to the pain.

How do we make a diagnosis of TN?

·         The diagnosis of TN is made on the basis of clinical description of facial pain (as described above). Detailed neurological examination by a neurologist is helpful in excluding a secondary cause. In cases of TN, clinical examination findings are normal (except for mild numbness over face in some cases).

·         TN gets misdiagnosed in some cases. Pain may seem to arise from the teeth region, as the trigeminal nerve supplies that region also. So, patients often visit a dental surgeon in the initial period. However, even after removal of teeth and dental treatment, the pain persists. I have had patients who were referred to me, only after several teeth were extracted. Occasionally, patient may visit an ENT surgeon as sometimes the pain seems to arise from behind the ear.

·         Generally, no investigations are required to make a diagnosis of TN. However, an MRI along with MR angiogram of the brain is required to exclude any secondary cause of TN.

What are the causes of TN?

Very often, no cause can be identified (these cases are called idiopathic). However, in many patients, there could be secondary causes which can be easily identified on the brain MRI scan. These may include:

·         Compression over the trigeminal nerve by a neighboring blood vessel,

·         Multiple sclerosis (a condition affecting brain and spinal cord, where the nerve covering-myelin sheath- is damaged)

·         Cystic mass lesions (which contain fluid)

·         Benign tumors (non-cancerous tumors)

·         Infections in the region of trigeminal nerve (bacterial or tuberculous).

·         Idiopathic- there are several patients suffering from TN, where no specific cause can be found out.

How do we treat trigeminal neuralgia?

TN is usually treated with medications (simple analgesics or medicines to relieve the neuropathic pain). These may include carbamazepine, oxcarbazepine, gabapentin, pregabalin, amitryptiline, etc. Drugs are started at a low dose, and the dose is titrated upwards depending on the treatment response and the occurrence of any side effects. More than half the patients do well with medical treatment alone. However, some patients do not respond to medical treatment or have significant adverse/side effects (such as drowsiness, dizziness, imbalance, skin rashes, etc). These patients can be treated by radio-frequency ablation or microvascular decompression.

Non-medical treatment of trigeminal neuralgia

1. Radio-frequency ablation of a portion of trigeminal ganglion (laser treatment). This procedure is carried out by radiation therapist in consultation with neurosurgeon.

2. Anesthetic blocks (injections of anesthetic drugs) of the trigeminal ganglion. This procedure is carried out by anesthetists.

3. Gamma knife radiosurgery (it is a radiation treatment and not a surgery).

4. Microvascular decompression- it is a surgical procedure where the trigeminal nerve is freed/released from any compression by a vessel or other surrounding tissues. This procedure is carried out by the neurosurgeon.

What is the outcome of TN?

TN responds well to treatment and most of my patients do well with medical treatment. I refer some patients for radiofrequency ablation or surgery. Most patients are pain-free after treatment. TN does not lead to death or paralysis or any physical disability.

(Footnote: At the time of writing this piece, Salman Khan has undergone a successful surgery, and is recovering well).

(This article was first published in March 2012 issue of health magazine Complete wellbeing)

DR SUDHIR KUMAR MD (INTERNAL MEDICINE), DM (NEUROLOGY)

SENIOR CONSULTANT NEUROLOGIST
APOLLO

HEALTH CITY, JUBILEE HILLS, HYDERABAD

Phone: 0091-40-23607777/60601066

Email: drsudhirkumar@yahoo.com

LISTENING TO PATIENTS VALUABLE IN MAKING A CORRECT DIAGNOSIS

Here, I describe an event that happened more than a decade back, when I was doing my residency in Neurology at CMC, Vellore.

A number of incidents during residency shape our method of practice in future. This communication is regarding an event that had a significant bearing on the way I deal with patients. The incident occurred in the first year of my residency in Neurology at a tertiary care centre. A 35-year-old lady consulted me for headache of six years' duration. It was described as a constant dull ache and had all the features suggestive of tension headache. A thorough clinical examination including blood pressure and optic fundi was normal. I reassured the patient and decided to start her on tricyclic antidepressants. The patient enquired how sure I was that she did not have a brain disease. With the enthusiasm and exuberance of youth, I told her I was pretty confident. I had almost forgotten this incident when she revisited me four months later. This time she had brought a computerized tomography scan of her brain that showed multiple cystic lesions. I could not believe my eyes. My confidence was shattered. However, the patient and her family were kind to me and emphasised that anyone could make a mistake. She was operated at our institute and made a complete recovery. As we have a common ward for Neurology and Neurosurgery, I happened to see her almost on a daily basis during the period she was admitted. Each meeting with her reminded me that her initial suggestion (that she might have a brain disease) was correct.

This incident had a major impact on my response to patients' opinions. As patients know their body (and disease) the best, it often helps to carefully listen to them. I have since made a number of correct diagnoses by just paying attention to what they say. It is very true that 'patients are our best teachers.'

Note: This article was first published in Journal of Postgraduate Medicine, 2004. Details are as follows. Kumar S. A Patient’s opinion is often valuable. J Postgrad Med [serial online] 2004 [cited 2012 Jan 11];50:216. Available from: http://www.jpgmonline.com/text.asp?2004/50/3/216/12580

Dr Sudhir Kumar MD (Medicine), DM (Neurology)
Senior Consultant Neurologist,
Apollo Health City, Hyderabad
Phone- 0091-40-23607777/60601066
drsudhirkumar@yahoo.com