Migraine Headaches: Types, Triggers and Treatments

Wednesday, June 25, 2014 2:48 PM comments (0)

migraine blogHeadaches can be more than just a pain; they can make work and day-to-day activities feel impossible. Headaches and migraines are as different as the individuals who experience them and the key to treating them is proper diagnosis.

Steven Meyers, MD, Neurologist and Headache Specialist at NorthShore, discusses common headache and migraine triggers and some treatment options that might help take the pain away:

How do you determine the cause of a migraine?
Many patients search for "the cause" when in fact most of the time there is no single cause. We believe migraine is a genetic disorder, meaning the tendency to experience migraine is passed down in your genes. Everyone wants a simple fix. If they can find the one thing to avoid or eliminate, they can eliminate their headaches but that rarely happens.

Migraine is a chronic illness and like all other chronic illnesses, the severity can vary from person to person. Treatment must be individualized to the specific patient, taking into account their individual desires regarding treatment options. I recommend always starting with your primary care physician. Schedule an appointment to discuss your headaches specifically. Don't wait for a yearly physical or when seeing your doctor for something else. If you cannot get the information you need then ask for a referral to a headache specialist.

How can you figure out what type of headache you are experiencing?
Proper diagnosis is essential for treatment. Your doctor should be able to make an appropriate diagnosis. If uncertainty persists, then you should see a headache specialist. Migraine, tension and cluster are the three most common primary headache disorders. Primary means no underlying cause, such as a tumor, aneurysm or other disorder, can be pinpointed as the cause of the headache.  Doctors have specific features and there are well-established criteria for making specific diagnoses. I cannot emphasize enough the importance of making a specific headache diagnosis. If your doctor cannot tell you the type of headache you have, get a second opinion.

Is there any evidence that migraines are genetic?
Yes. As I briefly mentioned earlier, migraine is definitely a genetic disorder. Most persons with migraine have a positive family history. In rare cases, specific genetic abnormalities can be tested for, but in the vast majority of migraine sufferers we don’t yet know what the genetic abnormality is.

What are some common migraine triggers?
There are many possible triggers and no two patients are the same. Why one trigger brings on a migraine in one person but not another is not known. Common triggers can include certain foods, though this has become somewhat controversial, with some recent studies questioning food as a trigger.

Alcohol, particularly red wine and beer, are common triggers. Missing meals, alteration in normal sleep patterns (too much or too little), weather changes, stress, and hormonal changes in women during the menstrual cycle are all possible triggers.

It is also important to keep in mind that triggers are rarely all or none. This means that a trigger may not trigger a migraine every time the patient is exposed; it may only happen every other or every third time. This makes identifying these triggers even more difficult.

What can you do about triggers that aren’t controllable, like weather and hormones?
In general I divide triggers into those you can control and those you can’t, like weather. Hormonal changes are potentially treatable but this can be tricky and there are pros and cons of pursuing this approach. Avoiding those triggers that are preventable could be helpful. When that is not sufficient, it’s time to speak to your doctor. If migraines occur frequently enough, then there are medications that can help prevent them or at least reduce the frequency of attacks.

What can a migraine sufferer do to shorten the duration of a migraine?
There are many options to treat migraine attacks. We refer to this type of treatment as abortive therapy. There are migraine-specific medications that we prefer to use. When these medications can’t be used for a specific reason or if they don’t work for a specific patient, we may prescribe other types of pain medications and/or anti-nausea medication. Some patients find relaxation, massage, or the use of ice or heat beneficial as well. Sleep, when possible, can also shorten the duration of an attack.

Is this normal to experience headaches at certain times of day, particularly in the morning?
Some patients do get headaches at very specific times of the day; however, it’s important that the type of headache be correctly diagnosed in order to come up with an appropriate treatment plan. Treatment of migraines that wake someone from sleep depends in part on how often this happens and under what circumstances. Sometimes a preventative medication at bedtime might be appropriate. 

Are there any new medications for migraines with minimum side effects?
Truthfully there is not much new out there at present. There are some very exciting new medications that we hope to see on the market in the not-too- distant future but drug development and research can be frustratingly slow. All medications have side effects, which vary greatly from person to person. There is some evidence that migraine sufferers are particularly prone to drug side effects and many persons will need to try a variety of medications before finding what works for them.

Are feverfew and butterbur effective herbal treatments for migraine prevention?
Feverfew and butterbur are two plant-based supplements available without a prescription. They both have been used for decades, particularly in Europe, to prevent headaches. They both have been studied in good scientific research trials in the U.S. and both have been found to be effective, safe and with few potential side effects. Overall, they tend not to be as effective as prescription medications in my experience but can be beneficial in certain persons and do tend to have fewer side effects.

The main problem is finding out what dose to use, as every supplement may be different in terms of strength and purity. Additionally, there are potential interactions with other medications. I would definitely recommend speaking to your doctor before starting any treatment.

What are your thoughts on combining acupuncture and chiropractic adjustments with conventional treatments from a neurologist for migraines?
Both acupuncture and chiropractic treatments have been studied and found to be helpful in some individuals with migraine. I have many patients who use these therapies and find them helpful either alone or in combination with "conventional" treatments.

When suffering from a headache, does consuming a little caffeine help a headache or make it worse? Any other recommendations, suggestions or treatments do you have to help ease the pain of a migraine headache?
Caffeine is interesting. Consuming caffeine can be helpful.  Several common headache medications add caffeine to make them more effective. Many patients will drink some coffee or cola along with whatever medication they take when they get a headache. However, the frequent/regular use of caffeine can actually cause headache or make headaches worsen over time. 

If you use a medication that contains caffeine such as Excedrin, be careful to follow the directions very carefully. These medications should not be used more than 1-2 days per week. I usually recommend that frequent headache sufferers limit caffeine consumption to the equivalent of 2-3 cups of coffee per day. Short of medication, some patients use relaxation therapy, biofeedback, ice, heat or sleep to treat migraine attacks.

Comment

Q&A: Brain Tumor Research, Treatment Options and Recovery

Tuesday, May 20, 2014 1:03 PM comments (0)

brain tumorIt’s normal for the diagnosis of a brain tumor to inspire of fear, anger and confusion. And it will for the estimated 70,000 people who will be diagnosed with a primary brain tumor—a tumor that begins in the brain—and the countless more who will be diagnosed with a metastatic brain tumor—a tumor that begins as cancer in another part of the body and spreads to the brain—each year. Acquiring the correct information both from your doctor and your own research is the key to finding a way through those initial feelings and deciding on a course of treatment.

As a part of National Brain Tumor Awareness Month, Ryan Merrell, MD, Neuro-Oncologist at NorthShore, answers our questions on brain tumors, both primary and metastatic, from current treatment options and on-going clinical trials at NorthShore, to potential causes of brain cancer and more: 

Often the first question after a brain cancer diagnosis is what the chances of survival are. What would be your answer to that question for patients with a metastatic brain tumor?
Survival in metastatic tumors depends heavily on the type of tumor. For example, many patients with metastases, which are tumors that spread from other areas of the body, from breast cancer have better survival than patients with metastases from melanoma. 

Also, within a particular tumor type, some subtypes do better than others. For example, certain mutations associated with non-small cell lung cancer often have better outcomes. Also, the extent of disease in the body is very important. If a patient has a cancer that has not spread to multiple organs, survival odds are better. We see some patients with metastatic brain tumors with long-term survival.

If you are diagnosed with brain cancer, would it be better to see a neuro-oncologist than an oncologist?
Most neuro-oncologists train in neurology first and then specialize in neuro-oncology. They are often better trained to tackle the specific neurologic challenges of brain tumors. That doesn’t mean that a medical oncologist (oncologist) is not capable. In fact, many medical oncologists at top centers specialize in taking care of brain tumors. I would make your decision more on how many brain tumor patients the physician sees per year and if that is a substantial portion of their practice.

Are there minimally invasive surgery options available for brain tumors or is a craniotomy still the only way to remove a tumor?
This is a provocative question. My sense is that the future of brain tumor surgery is moving towards less invasive procedures. For now, open craniotomies (big surgeries) are the gold standard. However, neurosurgical techniques are becoming more and more refined. For example, we are now using an endoscopic technique that allows the surgeon to make a smaller incision and disrupt less of the normal brain during surgery. The idea is that this will lead to shorter recovery times and better long-term outcomes. We also have a minimally invasive thermal laser ablation technique that we are currently using to treat metastatic tumors that develop delayed swelling after radiation (radiation necrosis). This technique allows a patient to go home the day after the procedure. We are looking to expand this procedure to the direct treatment of tumors as well.

What makes a brain tumor inoperable? If you are told you have an inoperable tumor, what can be done?
The location of the tumor in the brain is important. For example, tumors in the brainstem, motor cortex and deep brain structures (basal ganglia, thalamus) cannot be removed safely without harming the patient. These areas can be biopsied. 

Other brain locations are difficult but can be operated on by skilled neurosurgeons. I highly recommend getting a second opinion if you are told that a tumor is inoperable because it may be that the neurosurgeon you are seeing is not comfortable doing that surgery. At NorthShore, we are aggressive at operating on any tumor location, but are also very cautious not to undertake a surgery that would cause permanent neurologic harm to a patient.

Is rehab always necessary after brain surgery?
Not always. This depends a lot on the age of the patient, the presence of other medical problems and the location of the tumor. For example, an 80-year-old patient is more likely need rehab than a 40-year-old patient. A tumor that is near the motor cortex, which could cause weakness on one side of the body, would also likely require the patient to undergo rehab after surgery. We do, however, have many patients that go directly home after surgery. We have an outstanding inpatient rehab unit at Evanston that allows us to directly transfer patients to the unit a few days after surgery if necessary.

After surgery to remove a tumor, what is the typical treatment that follows?
This depends highly on the type of tumor, metastatic or primary, and covers a wide spectrum. Most tumors will require either radiation and/or chemotherapy after surgery. There are some malignant tumors—low-grade gliomas, for example—that can be watched after surgery. At a minimum, all malignant tumors require close follow-up with serial MRI scans after surgery.

What factors should be considered in deciding when to discontinue chemotherapy?
That depends a lot on the context. Stopping chemotherapy when the tumor is not growing or when it’s growing. For example, in glioblastoma, there is no evidence that giving more than 12 cycles of the chemotherapy drug temozolomide leads to better outcomes when the tumor is not growing. When a tumor is growing and we have exhausted all treatment options and the patient can no longer tolerate treatment, we have to make the difficult decision to stop the chemotherapy. Of course, the patient's decision is the most important. The patient has the right to stop chemotherapy at any time.

What percentage of malignant brain tumors in the US are caused by environmental factors vs. genetic factors or both?
The simple answer is that this is unknown. There are no known environmental risk factors for malignant brain tumors. The cell phone studies have not been revealing. It’s rare that malignant brain tumors occur in families. Even having a first-degree relative (sibling, child or parent) with a brain tumor doesn’t put a patient at increased risk. There are rare tumor syndromes associated with brain tumors. At NorthShore, we’re involved with an international study that studies both genetic and environmental risk factors for brain tumors. We hope to uncover some answers in the next few years.

So do cell phones cause brain tumors?
The answer is probably not. There have been several cell phone studies but none have shown definitively one way or another if cell phones are a risk factor. Many of my colleagues and I believe that the exposure a cell phone emits is theoretically too small to cause the development of a brain tumor, but, like many things in the brain tumor world, the jury is still out. It’s most likely fine to talk on cell phones with regard to brain tumor risk.

What are some of the best clinical trials for brain tumors? Are there any at NorthShore?
Unfortunately, there is no “best” clinical trial. Nobody in the world can make that claim. That is why they are trials. We participate in several clinical trials, the majority of which are for glioblastoma. Current clinical trials for glioblastoma involve targeted therapies and immunotherapies. We have both and have phase I, II and III trials. 

Find out more information on clinical trials at NorthShore here

How do you decide which clinical trial is the best one for you?
This is a tough question. There is no way for anyone to know which trial is better than another. If a particular trial appeared to be producing home run results, we all would steer patients to that trial. That has not happened yet.

I tell patients to choose trials based on the science behind them. Does a trial seem scientifically more interesting than another? Also, what does the trial require in terms of time commitment? Does the trial require weekly visits and a lot of travel time? Some patients prefer open label trials over randomized trials. Some patients prefer trials that allow crossover at the end, meaning that they can get the study drug if they were in the placebo group initially.

What is the brain tumor vaccine? Who does this work for?
Most vaccine therapies are designed for high-grade gliomas, and usually for glioblastoma (the highest grade glioma). We currently have three trials involving vaccines therapies for glioblastoma with two different types of vaccines.

On a national level, there are many different types of vaccine trials. A vaccine is just a term that implies immunotherapy, meaning that you are trying to engineer the immune system to mount a response against the brain tumor in a specific way.

What are your thoughts on the use of medical marijuana to help treat the symptoms that arise from having a brain tumor?
Like many physicians, I’m on the fence here. I think there are some symptoms—pain and nausea—that would clearly could benefit from medical marijuana; however, often, we are able to treat those symptoms by more traditional methods. I am open to the idea of using medical marijuana in select patients. We are waiting to hear from the state of Illinois and NorthShore regarding the logistics of how we will be able to prescribe it.

Dr. Merrell will be speaking on the subject of Malignant/High Grade Tumors: Update in Treatment and Care at American Brain Tumor Association’s Patient & Family Conference on Saturday, July 26th in Chicago. More information here

Comment

Parkinson's Disease Research at NorthShore Strives to Lead to Better Patient Outcomes

Friday, April 11, 2014 1:11 PM comments (0)

parkinsons

As part of National Parkinson’s Disease Awareness Month, Demetrius Maraganore, MD, Chairman of Neurology at NorthShore, shared some of the findings of his ongoing research into the genetic factors that influence Parkinson’s disease progression and outcomes. He also tells us why research like this is so important for Parkinson’s disease patients and their families: 

Why is funding for and research into Parkinson’s disease so important? 
It’s important because the treatments that we have available don’t prevent Parkinson’s disease (PD) or slow or halt its progression.  PD is characterized by progressive motor and cognitive impairment.  PD patients have a seven-fold increased risk of nursing home placement and a two-fold increased risk of death.  The annual cost of PD in the U.S. exceeds $23 billion. Presently 2% of people will develop PD during their lifetime, and the prevalence of PD is expected to double by 2030. The cumulative burden of PD to society is and will be staggering.  Our patients and their families deserve methods to predict, prevent and halt PD and those will only come through research.

How long have you been conducting research into Parkinson’s disease?  
My research in Parkinson’s disease (PD) started in 1989, when I was an honorary clinical and research fellow to the late Professor C. David Marsden at the National Hospital for Neurology and Neurosurgery in London, England.  Dr. Marsden was the founder of the international Movement Disorders Society and its official journal, Movement Disorders.  His associate, Professor Anita Harding, was a pioneer in the field of neurogenetics.  Together, we launched the first genetic studies of Parkinson’s disease.  

That has remained the focus of my research, including for 20 years on the faculty of the Mayo Clinic in Rochester, MN, and in the four years that I have been Chairman of Neurology at NorthShore. While my research at Mayo focused on identifying genetic factors that contribute to the cause of PD, my research at NorthShore has focused on understanding how those genetic factors influence disease progression and outcomes.  Our research aims to develop methods to predict outcomes in PD, and to use that information to improve neurological health.

Why have you focused the bulk of your career on the study and treatment of Parkinson’s?  
As a clinician, it’s very gratifying that there are many treatments that we can employ in the first many years to reduce the burden of the disease on patients and families.  However, I recognize that the benefits of the existing treatments wane with time, and I’m driven by the sense of urgency to identify the factors that contribute to the progression of Parkinson's disease. Our goal is to target those factors so that every individual patient can have the best possible outcome. 

For more information on the NorthShore Neurological Institute and the research being done at NorthShore, click here. 

Comment

It’s Nap Time

Friday, March 07, 2014 11:22 AM comments (0)

nappingA lack of sleep can leave you feeling groggy and foggy all day, impairing your ability to focus on work and even retain information. That’s not all; lack of sleep also decreases libido, ages skin and can inhibit your ability to lose weight. Chronic sleep deprivation—regularly forgoing the recommended 7 to 8 hours or due to other sleep disorders—can have serious consequences on your health, including increased risk for heart disease, heart attack, stroke, high blood pressure, diabetes and depression. In other words, maintaining good sleep habits is an essential part of a healthy lifestyle. And, unfortunately, most of us aren't doing that. 

If done correctly, there is great power in a well-timed nap. While you should not rely on naps to repair the damage done by inadequate sleep or chronic sleep deprivation, naps can recharge your energy levels and improve your mood. The key is to time them just right. Short naps are preferable. Longer naps may be taken on occasion to make up for an occasional lapse in sleep schedule.

Thomas Freedom, MD, Neurologist and Program Director of Sleep Medicine at NorthShore, breaks down nap time to help you achieve maximum benefits from a little daytime shuteye:

10 to 20 minutes. Often called the “power nap,” this short rest period is a great way to recharge your personal energy battery, boosting alertness and increasing your midday focus. Keep your power naps to 10 to 20 minutes because you’ll stay in lighter stages of non-rapid eye movement (NREM), which means you won’t wake up feeling groggy and can get right back to work feeling refreshed. Also try to take the nap early in the afternoon.

30 minutes or more. Word of warning: Naps longer than 20 minutes could leave you with sleep inertia, or grogginess that can last up to 30 minutes after waking. If you need to be back on your feet right away, keep your nap to less than 20 minutes. Otherwise, after the fog wears off, you’ll enjoy the same restorative benefits of the power nap.

60 minutes. If you find yourself forgetting information halfway through your day, 60 minutes of shuteye might be able to help. A nap between 30 and 60 minutes will get you to slow-wave sleep, which can help improve your decision-making skills and recollection of information. You’ll need to give yourself a little recovery time after an hour nap, as the effects of sleep inertia could be more pronounced. There is a possibility that a nap of this length could also disrupt your sleep at night.

90 minutes. A 90-minute nap gives you a full sleep cycle—from the lighter stages of sleep all the way to REM (rapid eye movement). A nap of 60 to 90 minutes can improve decision-making skills and even enhance creativity. At this length, make sure to nap with care. You don’t want to disrupt your regular sleep schedule or keep yourself up at night by napping too long during the day. Sleep inertia may also be more of an issue.

Do you take day-time naps to boost your energy levels?

Comment

Mind Games: Your Brain Needs a Good Workout, Too

Friday, November 22, 2013 1:08 PM comments (0)

mind exercisesEveryone knows your body needs exercise to stay in peak shape. But did you know your brain does too? Physical exercise is essential to the health of both your body and brain, but you can do even more to keep your brain in shape. Challenging your brain with cognitive exercises is another great way to keep your mind sharp.

Chad Yucus, MD, Neurology at NorthShore, answers questions and shares some ways to give your brain the workout it needs to stay sharp at any age:

Do brain teasers and puzzles actually help to keep your mind sharp? Are certain types of puzzles and activities better than others?
There are many types of cognitive activities that help to keep the brain sharp, involving word games and number games, such as crossword puzzles, Sudoku, computer games and board/card games.  There is no strategy that is particularly better than another, but learning a new hobby, game and/or language is a good way to keep the brain sharp.

Why would a new hobby be helpful?
Learning a new skill or starting a new hobby that requires skills you don’t typically use can be helpful because it challenges you to keep learning and function in a way that is not familiar. It’s a great way to stay mentally active whatever your age.

Who benefits from cognitive exercises and activities?
Everyone. 

How do you keep your brain healthy to prevent memory loss?
There is no strategy to truly prevent memory loss, but there are strategies to delay the effects of any pathology (changes caused by disease) that may be developing in the brain.  This is based upon building a cognitive reserve before any problems begin to develop. These strategies include the cognitive exercises above, physical exercise, social activities—spending time with friends, planning events—regular sleep patterns and a low-cholesterol Mediterranean diet.  

How much time should you devote each day to cognitive exercise?
Think of it in terms of regular physical exercise. Your brain and the rest of your body need about the same each day, approximately 30-60 minutes of cognitive and physical exercise every day is a good place to start.

How do you exercise your brain?

Comment

Childhood Epilepsy: What to Do in the Event of a Seizure and How to Prevent Injury

Friday, November 15, 2013 12:49 PM comments (0)

epilepsy smallCurrently about 325,000 American children under the age of 15 have epilepsy, with 200,000 new cases being diagnosed each year, according to the Epilepsy Foundation of America.  Epilepsy is a disorder involving repeated seizures, or episodes of disturbed brain function associated with changes in attention and/or behavior. Although some children will outgrow the disorder or can have it easily managed through medication, others may be more severely impacted throughout their lives.

Kent Kelley, MD, Pediatric Neurology, tells parents, caregivers and teachers what they should know in the event of a seizure as well as some steps they can take to prevent harm from seizures before they happen:

  • Always make sure your child is carrying or wearing some form of medical identification, if appropriate. Teachers and caregivers should be made aware of your child’s disorder and how to act should a seizure occur.
  • Monitor your child’s surroundings for potential hazards. Avoid nearby objects that could cause harm if your child were to have a seizure, such as a hot stove or lawn mower.
  • Even if your child has not experienced a seizure for some time, don’t adjust the dosage of medication without the advice and supervision of your child’s physician. In addition, before giving your child any other medication, check to make sure there will not be a negative reaction with his or her seizure medication. If you have questions, call your physician or pharmacist.
  • In the event of a seizure:
  1. Make sure that clothing isn’t restricting the neck and causing difficulty breathing.
  2. Do not try to hold the child down or restrain him or her.
  3. Remove any objects that could cause harm from around the child.
  4. After the seizure has subsided, position the child on his or her side to help keep the airway clear.
  5. Call 911 if the seizure lasts for longer than five minutes, the child cannot be awakened, or if another seizure begins shortly following the first. Depending on the type of seizure, different actions may need to be taken.

 

Comment

The Importance of Sleep to a Healthier You

Friday, May 24, 2013 10:48 AM comments (0)

sleepThe importance of a good night’s sleep can’t be overstated and not getting enough can lead to more than simply waking up on the wrong side of the bed.  Prolonged sleep deprivation can raise your risk for serious health problems like heart disease, diabetes and high blood pressure. Sleep isn’t a waste of time; it’s an investment in your health.

The benefits of sleep are many. According to Thomas Freedom, MD, Neurologist and Program Director of Sleep Medicine at NorthShore, a good night’s rest can improve:

  • Your smarts. Sleep is essential to critical thinking and learning. Losing out a night’s rest impairs these processes, affecting attention span, problem-solving skills and alertness. Prolonged sleep deprivation takes a toll on long-term memory, too. It’s during your deepest sleep that the brain does its housekeeping, storing and consolidating learned information and long-term memories.
  • Your happiness. One sleepless night is depressing but multiple sleepless nights might be a symptom of depression. Insomnia and sleep disorders are strongly linked to depression and prolonged sleep deprivation can aggravate already existing symptoms of depression. Studies have shown that people diagnosed with depression were far more likely to sleep less than six hours a night.
  • Your looks. It turns out the fountain of youth isn’t a fountain at all. The key to healthy, youthful skin is plenty of rest. When you don’t get enough sleep, the body releases increased amounts of the stress hormone cortisol and excess cortisol can break down skin collagen— the protein responsible for supple, line-free skin. 
  • Your health. Chronic sleep deprivation is a contributing factor in a number of serious health problems, including heart disease, diabetes and high blood pressure. Those who regularly fail to get enough sleep are at a higher risk for heart attack, stroke and heart failure. Lack of sleep can also add to your waistline. Sleep loss is linked in an increase in appetite and cravings for high-carbohydrate and high-fat foods.
  • Your sex life. If the mood never strikes, your sleep schedule could be to blame. Sleep-deprived men and women often report less interest in sex. Lack of sleep leads to lower energy levels, higher stress levels and fatigue, which all have a negative effect on libido. To spend more time in the sack, spend more time in bed.

Remember that the amount of sleep required varies with each individual, but most adults need approximately 7-8 hours a night. 

Do you think you get enough sleep each night? Do you make sleep a priority?

 

Comment

Parkinson's Disease: Symptoms and Progression

Thursday, April 25, 2013 11:32 AM comments (0)

April is National Parkinson’s Disease Awareness Month. All this month, we will feature a series of posts addressing Parkinson’s disease symptoms, genetics, treatment options and more from NorthShore neurologists—Demetrius Maraganore, MD, Aikaterini Markopoulou, MD, and Ashvini Premkumar, MD— to raise awareness about this common and often disabling neurological disorder.

by Demetrius Maraganore, MD, and Ashvini Premkumar, MD

symptomsIs it possible to detect PD before symptoms begin?

There is no established method of detecting Parkinson’s disease before symptoms begin.  Because patients with Parkinson’s disease may lose their sense of smell decades before the onset of their movement disorder, some investigators have explored the use of smell testing as a method of detecting Parkinson’s disease in at-risk subjects (e.g., persons who carry a rare gene mutation known to cause Parkinson’s disease). Persons can lose their sense of smell for many unrelated reasons though (e.g., following an upper respiratory infection, head trauma, or if they smoke). Loss of smell can precede other brain degenerations such as Alzheimer’s disease, so smell testing lacks the specificity needed for a predictive test.

A more promising approach is brain imaging using a radiopharmaceutical called DATSCAN. This is a compound that is injected into a vein and that binds to the endings of dopamine nerve cells in the brain. In Parkinson’s disease, dopamine nerve cells degenerate; hence, there is less binding of DATSCAN. The uptake and binding of DATSCAN can be measured using a single photon emission computerized tomogram or “SPECT” camera.  We are currently conducting a study at NorthShore to determine if persons with mild to moderate traumatic brain injury, who are at an 11-fold increased risk for Parkinson’s disease, have lower DATSCAN binding than persons without a history of brain injury. This study would demonstrate that it’s possible to detect Parkinson’s disease in at-risk subjects before symptoms begin. 

DATSCAN could prove useful as a method to develop asymptomatic Parkinson’s disease in at-risk subjects who could then be prescribed treatments or lifestyle changes that might delay or possibly even prevent the onset of Parkinson’s disease symptoms.  My research associate Dr. Ying Wu is also exploring the use of automated MRI brain measurements in the same brain injury population to see whether MRI may prove effective in detecting preclinical Parkinson’s disease changes in at-risk subjects.

Are PD symptoms or outcomes different between men and women? Between races?

My research collaborators and I have conducted several studies of gender differences in Parkinson’s disease. At every age men are 1.5 times more likely to develop Parkinson’s disease than women. We observed no convincing difference in survival for men and women with Parkinson’s disease. While there was no difference in motor outcomes, we observed that the risk for dementia was greater in men than in women with Parkinson’s disease. It's possible that estrogen protects against dementia in women.

My collaborators and I observed no important differences in the rates of Parkinson’s disease worldwide, and I’m not aware of any convincing data to suggest that symptoms of Parkinson’s disease or its outcomes differ according to race or ethnicity.

What are some of the later complications of Parkinson’s disease?

Typically we associate Parkinson’s disease with movement disorders. As the disease progresses, patients may develop balance difficulties that result in falls. As a result, patients become increasingly dependent on assistance in walking. For example, they may need a cane or a walker or someone to walk with them.  As the movement disorder progresses more, patients may be entirely unable to stand or walk even with assistance

Parkinson’s disease is not just a movement disorder though. About one in three patients develop a significant decline in memory and mental faculties, or what we call dementia.  Both falls and dementia are dreaded late complications of Parkinson’s disease because they are resistant to medical or surgical treatments and because they carry an increased risk for nursing home placement and even death. Predicting falls and dementia as late complications of Parkinson’s disease is a research priority of the Department of Neurology at NorthShore and a current focus of my research.

Is there a way to slow or halt the progression of PD?

There is no proven method of slowing or halting the progression of Parkinson's disease. Treatments that have been studied and that failed to provide evidence of neuroprotection are: selegiline, vitamins E and C, pramipexole, ropinerole, and COQ10.  There is some statistical evidence that carbidopa/levodopa therapy may slow motor progression in Parkinson's disease, but the benefits are trivial.

Azilect is being promoted as a neuroprotective agent, but it’s dubious because the beneficial effects were observed at smaller and not higher doses. The drug is also very expensive and prone to multiple drug-diet and drug-drug interactions. At best, the benefits are nominal. A recent medical advisory panel to the FDA voted 17 to 0 that Azilect should not be approved as a neuroprotective therapy in Parkinson's disease.

Inosine dietary supplementation, to increase blood uric acid levels, may be neuroprotective; however, it may also increase the risk for heart disease, stroke or dementia. There is some evidence that vitamin D deficiency is a risk factor for Parkinson's disease; however, there are no clinical trials to suggest that vitamin D therapy slows the progression of Parkinson's disease. Similarly, observational studies have suggested that non-steroidal anti-inflammatory drugs (NSAIDs) or cholesterol lowering medications (statins) are associated with a reduced risk for Parkinson’s disease, but clinical trials evidence of neuroprotection is lacking. There are some early clinical trials of the calcium channel blocker isradipine, which may have neuroprotective effects in animal models of Parkinson's disease. Though, the animal models of Parkinson's disease are not always informative, and some calcium channel blockers can actually cause reversible parkinsonism.

One big hope on the near horizon is therapies targeting the alpha-synuclein protein in Parkinson's disease, including a vaccine that is in early phase clinical trials.  However, while genetic studies have indicated that alpha-synuclein is neurotoxic prior to the onset of Parkinson’s disease symptoms, my research team recently provided genetic evidence that alpha-synuclein may be neuroprotective late in the disease process. So it’s unclear if therapies targeting alpha-synuclein in Parkinson’s disease will be effective and safe. 

Recent studies have suggested that exercise might slow the progression of Parkinson’s disease. Apart from exercise, I have no recommendations regarding neuroprotection at this time.

Once dementia starts is there anything that can be done to reduce the loss of memory?

There are certain “cognitive enhancing” medications that may be useful in improving cognitive symptoms and slowing the progression of dementia in patients with Parkinson’s disease. These include a class of drugs entitled cholinesterase inhibitors (rivastigmine, galantamine, donepezil). The Exelon patch in particular was specifically studied in Parkinson’s patients and obtained FDA approval for treatment of Parkinson’s related dementia. Memantine, an NMDA receptor antagonist, has been FDA approved for treatment of Alzheimer’s dementia; however, in clinical practice, it has also been found to be helpful in certain patients with Parkinson’s disease related dementia. In addition, nonpharmacological interventions including exercise, social stimulation, and cognitive rehabilitation can be helpful in the treatment of dementia in Parkinson’s disease.

Apart from genes, are there any environmental risk factors for PD? 

My research team was funded by the National Institute for Environmental Health Sciences for more than ten years to study both genetic and environmental risk factors for Parkinson’s disease. We found that pesticide exposure, both occupational and gardening-related, was associated with a two-fold increased risk for Parkinson’s disease. In particular, exposure to herbicides carried an increased risk. Of the herbicides recalled by our study subjects, the one most significantly associated with Parkinson’s disease was 2,4-Dichlorophenoxyacetic acid, a major component of Agent Orange. There have been reports that Vietnam War veterans are at an increased risk for Parkinson’s disease. Pesticides may contribute to an increased risk for Parkinson’s disease by causing the alpha-synuclein protein to misfold and form toxic accumulations within vulnerable nerve cell regions.

My research team also observed that head trauma may be a risk factor for Parkinson’s disease. A closed head injury that produced loss of consciousness or that required hospitalization was associated with an 11-fold increased risk for Parkinson’s disease.  Head trauma may contribute to an increased risk for Parkinson’s disease by causing an acute spike in alpha-synuclein levels.

While my research team observed no evidence for an interaction of pesticide exposures and alpha-synuclein gene variants, a research team from California recently reported an interaction of head trauma and alpha-synuclein gene variants in Parkinson’s disease. Currently, my research team at NorthShore is conducting a brain imaging study of mild traumatic brain injury to determine if there are Parkinson’s disease-like abnormalities in the brain scans of persons exposed to head trauma, even in the absence of symptoms of Parkinson’s disease. We will also consider the interaction of traumatic brain injury and alpha-synuclein gene variations in that study.

Comment

Parkinson's Disease: Treatment

Tuesday, April 16, 2013 4:36 PM comments (0)

April is National Parkinson’s Disease Awareness Month. All this month, we will feature a series of posts addressing Parkinson’s disease symptoms, genetics, treatment options and more from NorthShore neurologists—Demetrius Maraganore, MD, Aikaterini Markopoulou, MD, and Ashvini Premkumar, MD— to raise awareness about this common and often disabling neurological disorder.

by Ashvini Premkumar, MD

treatmentWhat are the most effective medications for the treament of Parkinson’s disease?
The most effective medications for the treatment of Parkinson’s disease are the dopaminergic medications. Carbdiopa/levodopa is by far the most effective, followed by dopamine agonists and lastly mao-b inhibitors.  Non-dopaminergic medications include anticholinergics, which are sometimes useful for treatment of tremor but have to be used with caution because of the side effect profile, particularly in elderly patients.

What are the most common side effects of carbidopa/levodopa? 
The most common side effects for carbidopa/levodopa that we see clinically include: nausea/vomiting, lightheadedness, sleepiness, hallucinations, and dyskinesias.

Do you recommend the early use of carbidopa/levodopa? Delay its use?  
The early vs. delayed use of carbidopa/levodopa has been debated for many years.  The crux of the debate rests on the concern that early use of carbidopa/levodopa may increase one’s risk for motor complications, namely fluctuations (“on” and “off” periods) and dyskinesias. The risk is approximately 40 percent within four to six years, particularly among young patients. Whether or not to start carbidopa/levodopa has to be highly individualized decision, which will be based on many factors, including disease severity, age, co-existing symptoms (i.e. cognitive impairment) and occupational concerns.

Please discuss Neupro transdermal therapy
Neupro transdermal therapy, or the rotigotine patch, is dopamine agonist that is FDA approved for the treatment of Parkinson’s disease. It can be used in early Parkinson’s disease. It also can be used as an adjunctive medication in advanced Parkinson’s disease as it was shown in studies to reduce “off” time by roughly one hour a day. It has also been approved in the treatment of moderate to severe restless legs. The side effects include: nausea/vomiting, somnolence (sleep attacks), reactions at application site, dizziness, anorexia and compulsive behavior. The specific benefit of Neupro, like other extended-release dopamine agonists, is that it maintains as constant a level of drug as possible throughout the day.

Some say that exercise eases Parkinson's diease symptoms. What exercises or physical activities are recommended for people with Parkinson’s disease?
We recommend an exercise program that combines aerobic activity and core muscle strengthening. And this should preferably be complemented by exercises aimed at balance and stretching (i.e. yoga and Tai Chi). 

Is it safe to ride a bicycle with PD? 
This question needs to be routinely addressed by the patient’s treating neurologist. In general, in the early stages of PD, where balance is not significantly affected, it’s considered safe. However, once postural instability becomes noted, either by reported falls or upon routine examination, then it would be advisable to ride only stationary bicycles.

How can I prevent falls if I have PD? 
Prevention of falls should be emphasized at each clinic visit with one’s treating neurologist. The best way to prevent falls is to be educated as to what causes falls in Parkinson’s disease and then to take every precaution to avoid those “missteps.” 

 

Comment

Parkinson's Disease: Deep Brain Stimulation

Tuesday, April 09, 2013 10:50 AM comments (0)

April is National Parkinson’s Disease Awareness Month. All this month, we will feature a series of posts addressing Parkinson’s disease symptoms, genetics, treatment options and more from NorthShore neurologists—Demetrius Maraganore, MD, Aikaterini Markopoulou, MD, and Ashvini Premkumar, MD— to raise awareness about this common and often disabling neurological disorder.

by Aikaterini Markopoulou, MD

What is DBS?
Deep brain stimulation is a type of surgical treatment for Parkinson’s disease. It involves the insertion of electrodes into specific areas of the brain that control movement. The electrodes are connected to a battery that is placed under the skin in the upper part of the chest. Electrical current that passes through the electrode stimulates these brain areas on one side of the brain. This stimulation results in improvement of tremor and slowness or stiffness on the other side of the body.

Who is a good candidate for DBS?
To be a candidate for DBS surgery a number of conditions have to be met:

  • A diagnosis of typical Parkinson’s disease that involves a combination of symptoms such as tremor, stiffness, slowness of movement or balance problems
  • Duration of disease symptoms for more than five years
  • Symptoms that respond well to treatment with levodopa
  • Presence of complications of levodopa therapy
  • Absence of dementia
  • No other diseases or conditions that significantly affect overall health (e.g., conditions that affect blood clotting, heart and lung disease, moderate to severe depression, pregnancy)

Is DBS covered by Medicare?
Yes, DBS is covered by Medicare.

When a patient has bilateral DBS is it necessary to have two stimulators, or will one suffice?
In the majority of Parkinson’s cases, symptoms affect both sides of the body; therefore, electrodes are inserted in both sides of the brain. In some cases where the symptoms affect mostly one side, the electrode can be inserted only in the opposite site of the brain.

If you have DBS, how does it affect your ability to get through airport checks, metal detectors, etc.?
Each patient is provided with an identification card that includes information about the implanted stimulator. The TSA agent should offer a private screening or screening with a manual wand instead of the patient walking through a metal detector.

What percentage of DBS surgeries result in complications? What complications might a patient encounter?
The DBS surgery may result in complications both during the implantation and after surgery, which include bleeding at the electrode insertion site that can be fatal, hardware malfunctioning, and infection and symptom worsening. In a large multicenter clinical trial, 7.5% of patients developed intracranial hemorrhage, 10.6% device-related infection and 8.1% one-sided weakness.

How long is DBS effective?
Studies that have followed patients for ten years have been published and the DBS remained effective throughout the ten-year interval.

Are there any long term risks associated with DBS?
DBS therapy remains a safe treatment option for Parkinson’s patients for at least ten years.

 

Comment
12>
× Alternate Text