Study: Concussions and Alzheimer's are linked

According to a new study, older adults with memory issues and Alzheimer's disease also generally have a history of concussion.

Older adults with memory problems and a history of concussion have more buildup of Alzheimer's disease-associated plaques in the brain than those who also had concussions but don't have memory problems, according to a new study.

''What we think it suggests is, head trauma is associated with Alzheimer's-type dementia -- it's a risk factor," said study researcher Michelle Mielke, an associate professor of epidemiology and neurology at Mayo Clinic Rochester. "But it doesn't mean someone with head trauma is [automatically] going to develop Alzheimer's."

Her study is published online Dec. 26 and in the Jan. 7 print issue of the journal Neurology.

Previous studies looking at whether head trauma is a risk factor for Alzheimer's have come up with conflicting results, she noted. And Mielke stressed that she has found only a link or association, not a cause-and-effect relationship.

In the study, Mielke and her team evaluated 448 residents of Olmsted County, Minn., who had no signs of memory problems. They also evaluated another 141 residents with memory and thinking problems known as mild cognitive impairment.

More than 5 million Americans have Alzheimer's disease, according to the Alzheimer's Association. Plaques are deposits of a protein fragment known as beta-amyloid that can build up in between the brain's nerve cells. While most people develop some with age, those who develop Alzheimer's generally get many more, according to the Alzheimer's Association. They also tend to get them in a predictable pattern, starting in brain areas crucial for memory.

In the Mayo study, all participants were aged 70 or older. The participants reported if they ever had a brain injury that involved loss of consciousness or memory.

Of the 448 without any memory problems, 17 percent had reported a brain injury. Of the 141 with memory problems, 18 percent did. This suggests that the link between head trauma and the plaques is complex, Mielke said, as the proportion of people reporting concussion was the same in both groups.

Brain scans were done on all the participants. Those who had both concussion history and cognitive [mental] impairment had levels of amyloid plaques that were 18 percent higher than those with cognitive impairment but no head trauma history, the investigators found.

Among those with mild cognitive impairment, those with concussion histories had a nearly five times higher risk of elevated plaque levels than those without a history of concussion.

The researchers don't know why some with concussion history develop memory problems and others do not.

The research was funded by the U.S. National Institutes of Health, among several other supporters.

The study adds valuable information for experts in the field, said Dr. Robert Glatter, director of sports medicine and traumatic brain injury in the department of emergency medicine at Lenox Hill Hospital, in New York City. Glatter, who is also a former sideline physician for the National Football League's New York Jets, reviewed the new study findings.

Other studies, he said, often rely on postmortem information. In the Mayo study, participants had to have loss of consciousness as a measure of having a concussion history, Glatter noted. However, he added, the new thinking is that loss of consciousness is not necessary to define a concussion -- one can occur without that.

The effect of head injury may be cumulative over time in the development of Alzheimer's, he said. In the past, experts thought only severe head trauma was linked with Alzheimer's, but less severe injury may actually be relevant as well, he added.

Some other factor or factors yet to be discovered may be at play, Glatter said.

Both Mielke and Glatter stressed that concussions don't automatically lead to Alzheimer's. "Not all people with head trauma develop Alzheimer's," Glatter said.

"If you do hit your head, it doesn't mean you are going to develop Alzheimer's," Mielke said, although "it may increase your risk."

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How caffeine disrupts your sleep

New research looks into the specifics of how late-in-the-day caffeine can disrupt your sleep at night.

You hear it all the time when it comes to sleep: Don't drink caffeine too late in the day. It's among the most common sleep tips -- and it's a good one. Caffeine, with its stimulant effects, is disruptive to good sleep. And these days, with the popularity of energy drinks and other caffeine-laden beverages and snacks, it's not difficult to wind up consuming caffeine throughout the day, even if you've set your coffee cup aside. The negative health consequences of too much caffeine also extend beyond sleep problems. Research shows that caffeine may contribute to cardiovascular problems. A recent large-scale study also suggeststhat heavy caffeine consumption -- more than four 8-ounce cups of coffee per day on a daily basis -- is linked to higher mortality rates in men and women.

But how late in the day is too late in the day to be consuming caffeine? Despite consensus about caffeine's sleep-disrupting effects, recommendations about the timing of caffeine consumption -- and when it's best to stop for the day -- can vary widely. Though an abundance of research has been conducted to establish caffeine's negative effects on sleep, very little attention has been paid to the specific timing of caffeine consumption relative to bedtime.

A new study attempts to fill in some of these important specifics about the effects of late-afternoon and early-evening caffeine consumption on nightly sleep. Researchers at Michigan's Henry Ford Hospital's Sleep Disorders & Research Center and Wayne State College of Medicine analyzed the sleep-disruptive effects of caffeine consumption at different lengths of time before bedtime. They found that caffeine consumed even six hours before bedtime resulted in significantly diminished sleep quality and sleep quantity. This is believed to be the first study to investigate directly the effects of caffeine at specific times before nightly sleep.

The study included 12 adult men and women, all of whom were healthy and were normal sleepers who in their regular lives were moderate consumers of caffeine. During the study period volunteers kept up their normal sleep routines, which included bedtimes between 9 p.m. and 1 a.m. and wake times between 6 a.m. and 9 a.m. Participants' total nightly sleep duration fell somewhere in the range of 6.5 to 9 hours per night, with no regular habit of napping during the day. Throughout the study researchers tracked sleep by having participants keep sleep diaries and by using at-home sleep monitors. Participants were given doses of caffeine in pill form as well as placebo pills, on a schedule that enabled researchers to measure the sleep-disruptive effects of caffeine taken at three different points: at bedtime, three hours before bedtime, and six hours before bed. They found significant disruptions to sleep as a result of caffeine taken at all three points:

• Caffeine consumed zero, three, and six hours before bedtime significantly reduced total sleep time. Even caffeine consumed six hours before bed reduced total nightly sleep amounts by more than one hour.
• Caffeine consumed at all three points diminished sleep quality. Caffeine taken three and six hours before bedtime, as well as caffeine consumed at bedtime, significantly increased the amount of time spent awake during the night.
• Disruptions to sleep as a result of caffeine were perceived by volunteers (as recorded in sleep diaries) for caffeine consumed at bedtime and three hours before bed, but were not reported for caffeine taken six hours before bed. However, sleep monitors measuring total sleep time, and sleep efficiency (time spent sleeping relative to total time spent in bed) showed that caffeine consumed six hours before bedtime had significant detrimental effects to both.

This last finding is especially important, because it suggests that people can't -- and shouldn't -- rely entirely on their own perceptions of how much or little caffeine affects their sleep, especially caffeine consumed in the afternoon. Even if you don't feel that late-afternoon cup of coffee has a negative impact on your sleep, this study suggests that it is likely to be interfering nonetheless. This is one reason that I have long recommended a 2 p.m. cut off time for caffeine consumption.

Remember, limiting caffeine doesn't mean removing it entirely from your daily routine. A moderate amount of caffeine, consumed at the right times, can be useful and evenhealthful, stimulating alertness and energy. These new findings provide us with some really important specifics about just how significantly late-in-the-day caffeine can undermine a good night's sleep. Want to enjoy your coffee without wrecking your sleep? Follow these basic suggestions for consuming caffeine in a sleep-friendly way:

Stick to a 2 o'clock cut off. As this current study shows, late-afternoon caffeine can cause problems for your sleep, even if you aren't aware of it. To avoid sleep disruption, restrict your caffeine consumption primarily to the morning hours. If you do have a midday cup of coffee, make sure to drink it before 2 p.m.

Taper caffeine as the day progresses. Start your day with your most highly caffeinated beverage and ease up on the caffeine as the morning goes on. First thing in the morning is likely when you'll crave caffeine the most, and when it can do you the most good in terms of boosting energy and shaking off the effects of a night's sleep. Switch over to tea or decaffeinated coffee as the morning continues, to keep overall daily caffeine amounts moderate and be comfortably caffeine-free by mid-afternoon.

Avoid jumbo drinks. These days, everything seems to be "super-sized" -- and caffeinated drinks are no exception. From a 20-plus-ounce latte or soda to a caffeine-packed energy drink, a lot of caffeine products deliver way more of the stimulant than is healthful. Stick to something much closer to the old-fashioned 8-ounce cup, and savor it.

Don't ignore your sleep problems. Being tired makes us more likely to feel the need for caffeine, and that extra consumption can in turn make sleep problems worse. Avoid this sleep-disruptive cycle by making sleep a daily priority. Practice good sleep hygiene and talk to your doctor about how you are sleeping, particularly about any problems that arise.

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Children's internal clock could result in trouble sleeping

This article discusses how a child's internal clock, which regulates their natural melatonin levels, could result in the child fighting off sleep at bedtime.

"Just one more story, please?" ''I need a glass of water." ''Mom, I can't sleep!"

When youngsters continually struggle to fall asleep at night, new research suggests maybe their body clock doesn't match their bedtime.

That doesn't mean tots should be up at all hours.

"Just like nutrition and exercise, sleep is critical for good health," said sleep scientist Monique LeBourgeois of the University of Colorado, Boulder, who is leading the research.

The ultimate goal is to help reset a delayed sleep clock so that young children can settle down more easily, she said. Hint: It seems to have a lot to do with light.

We all have what's called a circadian rhythm, a master biological clock, that regulates when we become sleepy, and when we're more alert. Those patterns vary with age: It's the reason teenagers are notorious for late nights and difficult-to-wake mornings.

But how does that clock work in preschoolers, who need more sleep than older kids or adults? A first-of-its-kind study tracked 14 healthy youngsters for six days to begin finding out.

The children, ages 2½ to 3, wore activity monitors on their wrists to detect when they slept. Parents kept diaries about bedtime routines.

Then on the last afternoon, researchers visited each home, dimming lights and covering windows. Then, every 30 minutes for six hours leading up to the child's appointed bedtime, they also coaxed each tot to chew on some dental cotton to provide a sample of saliva.

The reason: To test for levels of a hormone named melatonin that is key to the sleep cycle and also sensitive to light. At some point every evening, people's melatonin levels surge and a while later, they begin to feel sleepy. Among adults who sleep well, that melatonin rise tends to happen about two hours before whatever is their chosen bedtime.

For preschoolers, the new study found that on average, the melatonin surge occurred around 7:40 p.m. The children tended to be tucked in around 8:10 p.m., and most were asleep 30 minutes later, LeBourgeois reported in the journal Mind, Brain and Education.

When melatonin rose earlier in the evening, tots who hit the sack around 8 fell asleep a bit faster. But when the melatonin surge was closer to bedtime, the youngsters were more likely to fuss or make curtain calls after lights-out.

Two children in the study actually were tucked in before their rise in melatonin ever occurred, and it took them up to an hour past bedtime to fall asleep, she said.

"We don't know what that sweet spot is yet," LeBourgeois said, but the data suggest bedtime is easiest if the melatonin surge occurred at least 30 minutes earlier.

The study reinforces what doctors have long suspected is one bedtime barrier, said Dr. Jyoti Krishna, a pediatric sleep expert at the Cleveland Clinic. Other factors can disrupt a child's sleep, too, such as noise, stress or anxiety, or disrupted home routines, he cautioned.

"But this paper reminds us that, hey, there is a time that the body is more ready to sleep than at other times," Krishna said.

The National Institutes of Health says preschoolers need 11 to 12 hours of sleep each day; some typically comes from an afternoon nap.

Parents don't have melatonin tests as a guide, so Krishna advises looking for cues when setting a bedtime — yawning, rubbing eyes — and then to adjust that bedtime as the child gets older.

"The melatonin onset and our body rhythms change," Krishna said. "You can't stick to what worked two years ago with this child, because this child is now a different child."

About 25 percent of young children experience some type of sleep difficulty, including trouble settling down at bedtime, LeBourgeois said. Harried parents aside, there's concern that early-in-life bedtime frustration might lead to more persistent sleep trouble.

"Listen to your child's physiology," she advised. Some steps that might help:

—Research shows that in adults, too much light in the evening delays the melatonin surge and subsequent sleepiness. While there's no data in young children yet, LeBourgeois says dimming the lights about an hour before bedtime makes sense.

—Avoid electronics near bedtime, because they generate a specific type of light that triggers wakefulness. LeBourgeois was horrified to hear one parent offer a sleepless youngster an iPad to play with as long as the child stayed in the bedroom.

—And make sure blackout shades aren't keeping your children from getting enough morning sunlight, she said. Light in the morning also is key to keeping the biological sleep clock on schedule.

Stay tuned: With funding from the National Institute of Mental Health, LeBourgeois has begun a larger study that will track sleep patterns of 40 2-year-olds until they're 5. She'll also measure their light exposure, and periodically record their brain waves during sleep, in a bid to better understand the influence of sleep patterns on children's development.

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Autism checklist improved for diagnosis in toddlers

A checklist used as a screening tool for autism has successfully been improved for diagnosis in toddlers.

An updated screening tool that physicians administer to parents to help determine if a very young child has autism has been shown to be much more accurate than earlier versions at identifying children who could benefit from further evaluation, according to researchers supported by the National Institutes of Health.

The Modified Checklist for Autism in Toddlers — Revised, with Follow-Up (M-CHAT–R/F) — is a free, two-step screening tool used to detect children likely to have autism. It is intended for use at regular well-child checkups for children 16 to 30 months old. With the M-CHAT-R/F, health care providers can classify a child’s risk of having autism as low, medium or high, on the basis of parents’ answers to 20 questions.

“This checklist can more accurately identify children likely to have autism so they can get the treatment and support they need,” said Alice Kau, Ph.D., of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the NIH institute that funded the study. “Given that the typical autism diagnosis occurs at age 4, it also offers the possibility of detecting autism much earlier — during regular doctor’s visits when a child is 18 months or 2 years old. And earlier intervention has been shown to improve outcomes for children with autism.”

A score in the high-risk range warrants a referral for further evaluation for possible autism. For a child determined to be at medium risk, M-CHAT R/F includes a follow-up questionnaire used soon after the original evaluation to obtain additional information needed to more definitively classify the child as either high risk or low risk.

Based on the M-CHAT-R/F classifications, the researchers found that a smaller proportion of children received a medium- or high-risk assessment (7 percent) than with earlier versions of the checklist (9 percent). However, more total cases of autism were detected with the revised checklist than with earlier versions (67 cases per 10,000 screened vs 45 cases per 10,000 screened).

Of the more than 16,000 children evaluated with the screening tool, 93 percent of the children screened were considered low-risk, 6 percent were in the medium-risk range and 1 percent were considered high-risk.

Of all the children who determined by the test to be at risk after the M-CHAT-R/F follow-up, 95 percent were eventually found to have some form of developmental delay, including more than 47 percent with autism spectrum disorder.

First author Diana L. Robins, Ph.D., of Georgia State University (GSU), in Atlanta, conducted the research with GSU colleague Karís Casagrande, and Marianne Barton, Ph.D., Chi-Ming Chen, Ph.D., Thyde Dumont-Mathieu, M.D., M.P.H., and Deborah Fein, Ph.D., all of the University of Connecticut in Storrs. Dr. Fein was the study’s senior author.

The findings appear in Pediatrics.

The researchers updated an earlier version of the autism screening tool, adding examples, rephrasing some questions and dropping others that previously did not elicit strong responses. Using the revised tool, the researchers worked with health care providers to screen more than 15,000 toddlers considered at low risk for autism.

“Earlier tools cast a wider net, but these refinements will allow health care providers to focus energy where it is needed most and will reduce the number of families who go through additional testing but which ultimately do not need treatment interventions,” said Dr. Fein.

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When you should get checked for sleep apnea

This article outlines what sleep apnea is and the process by which diagnosis and treatment occur.

Eighteen million Americans are estimated to suffer from sleep apnea, according to the National Sleep Foundation.

Sleep apnea is a common disorder, with a person having one or more pauses in breathing or experiencing shallow breaths while sleeping. The pauses can last a few seconds to several minutes. Thirty or more such pauses are possible in a single hour.

The result is a poor quality of sleep and daytime fatigue. The condition is usually noted by a family member, not the person with the disorder.

Dr. Anne Magauran at the Center for Sleep Disorders at Exeter Hospital said sleep apnea is treatable and she enjoys helping patients get a better night's sleep. She said anyone who is constantly tired during the day should discuss the problem with their primary care physician because a sleep disorder can be the cause and sometimes people are not aware they have sleep apnea issues.

"Sleep apnea is possible at any age," Magauran said. "When a person is referred to us, we have a list of questions called the Stop Bang questionnaire. If they answer yes to three or more of the questions, we suspect a sleep disorder and may do a sleep study."

Among the questions are whether the person snores, feels tired during the day, has high blood pressure or is overweight. Also, patients are asked whether anyone has ever observed them stop breathing while they are asleep.

"Sleep apnea is more common in people over the age of 50 and it is more common in men than in women," Magauran said. "We get referrals from primary care doctors or from specialists like pulmonary or cardiology because this increases the risk of heart attacks or strokes."

Once a referral is made, Magauran will conduct a detailed interview with the patient for a complete medical history, which includes lifestyle, medications, intake of caffeine and alcohol, exercise, weight and neck size — all factors in sleep disorders. Her questions also include the length of time a person has had sleep problems. She said people who say they are suffering from insomnia are often surprised to learn sleep apnea can be a cause.

Once diagnosed, sleep apnea requires long-term management and possibly surgery to correct airway issues. The best way to diagnose sleep apnea is for medical experts to conduct a sleep study. During the overnight study, doctors observe a patient and measure brain waves, eye and chin movements, heart rate and rhythms, respiration, levels of oxygen and carbon dioxide in the blood, and leg movements.

A sleep study can be done in a medical setting or at home. Magauran said a home study has less monitoring but does use an apparatus that the patient wears to bed. The device records the way the person sleeps and it is returned to the sleep center to be analyzed. Then a treatment plan is developed if necessary.

"Sleep apnea has defined criteria," Magauran said. "We look at how many times per hour the airway narrows or closes for 10 seconds or more, associated with a drop in oxygen and patient arousal."

Untreated sleep apnea can increase the risk of high blood pressure, heart attacks and stroke. It can worsen arrhythmias and diabetes. People suffering from poor sleep are more likely to be involved in car crashes and to have job performance issues.

There are three types of sleep apnea. Obstructive apnea comes from a blockage of the airway, usually the result of soft tissue that collapses and closes the rear of the throat during sleep. In central apnea, the airway is not blocked but the brain fails to signal the muscles to breathe. Mixed apnea is a combination of the first two conditions.

In mild cases, treatment may involve the use of decongestants and positional therapy. Some people snore when lying on their back and teaching them to sleep in a different position can help.

"There are devices, like an anti-snore belt that helps patients stay off of their back, if they can tolerate them," Magauran said. "It's not for everyone."

Oral devices such as a continuous positive airway pressure (CPAP) device can be used successfully in some patients.

Surgical methods can be used in adults to open a compromised airway. In children, tonsils and adenoids may be the culprit and surgery can resolve apnea completely.

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Study: Cognitive behavioral therapy can help kids with migraines

A study shows that symptoms of chronic migraines in children are reduced with cognitive behavioral therapy (CBT).

Among children and adolescents with chronic migraine, the use of cognitive behavioral therapy (CBT) resulted in greater reductions in headache frequency and migraine-related disability compared with headache education, according to a study appearing in the December 25 issue of JAMA.

"In adults, more than 2 percent of the population has chronic migraine and in children and adolescents the prevalence is up to 1.75 percent. In pediatric patients who seek care in headache specialty clinics, up to 69 percent have chronic migraine; however, there are no interventions approved by the U.S. Food and Drug Administration for the treatment of chronic migraine in young persons. As a result, current clinical practice is not evidence-based and quite variable," according to background information in the article.

Scott W. Powers, Ph.D., of Cincinnati Children's Hospital Medical Center, and colleagues randomized 135 participants (79 percent female) 10 to 17 years of age diagnosed with chronic migraine (≥ 15 days with headache/month) and a Pediatric Migraine Disability Assessment Score (PedMIDAS) greater than 20 points (disability score range: 0-10 for little to none, 11-30 for mild, 31-50 for moderate, >50 for severe) to CBT (n = 64) or headache education (n = 71). The study was conducted in the Headache Center at Cincinnati Children's Hospital between October 2006 and September 2012; 129 participants completed 20-week follow-up and 124 completed 12-month follow-up. The interventions consisted of 10 CBT or 10 headache education sessions involving equivalent time and therapist attention; CBT included training in pain coping, modified to include a biofeedback component. Each group received amitriptyline; follow-up visits were conducted at 3, 6, 9, and 12 months.

On average, at the beginning of the trial, participants reported 21 of 28 days with a headache and a PedMIDAS of 68 points, indicating a severe grade of disability. From pretreatment to posttreatment, CBT resulted in a decrease of 11.5 headache days vs. 6.8 days with headache education. At 12-month follow-up, 86 percent of CBT participants had a 50 percent or greater reduction in days with headache vs. 69 percent of the headache education group; 88 percent of CBT participants had a PedMIDAS of less than 20 points (mild to no disability) vs. 76 percent of the headache education group.

"Now that there is strong evidence for CBT in headache management, it should be routinely offered [to younger people] as a first-line treatment for chronic migraine along with medications and not only as an add-on if medications are not found to be sufficiently effective. Also, CBT should be made more accessible to patients by inclusion as a covered service by health insurance as well as testing of alternate formats of delivery, such as using online or mobile formats, which can be offered as an option if in-person visits are a barrier," the authors write.

System barriers may affect the likelihood of CBT being implemented as a first-line treatment for pediatric chronic migraine, writes Mark Connelly, Ph.D., of Children's Mercy Hospitals and Clinics, Kansas City, in an accompanying editorial.

"Creative means of delivering CBT for pediatric chronic migraine (e.g., via telehealth or Internet-based programs, using behavioral health consultants in primary care offices) will be necessary for reducing current access and referral barriers that could be encountered by many families and physicians. Widening the availability of interdisciplinary models of training and treatment delivery also will be important for helping ensure that children with chronic migraine routinely receive combination therapies rather than being referred for psychological therapy only after other approaches fail."

"Ideally with the efforts of the health care community and other relevant stakeholders, the suggestion by Powers et al to consider CBT along with medication as a first-line treatment for chronic migraine in children will be implemented into practice well before the typical translation gap. Additional studies are warranted, however, to identify methods of preventing chronic migraine development and to determine the medications and combination therapies that further maximize improvements in health and quality of life outcomes for children and adolescents with chronic migraine."

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How Botox can help with Cluster Headaches

This article discusses research that is currently being done to turn Botox into a treatment for cluster headaches.

Botox is best known as a facial wrinkle remover, but if all goes well with the research, someday soon it may be a treatment option for cluster headache. At least that is the hope of a team of scientists at the Norwegian University of Science and Technology (NTNU).

Why Botox?
Botox (onabotulinumtoxinA) is a neurotoxin and a drug that uses a potent poison called botulinum toxin, which is derived from the bacterium Clostridium botulinum. When it is injected into facial muscles, it paralyzes them temporarily and causes wrinkles to disappear for several months.

Similarly, injections of the toxin are used to block nerve signals that cause muscles contractions in cerebral palsy and bladder spasms, to block postsurgical pain and foot pain, and to temporarily relax eye muscles in people with strabismus (misaligned eyes). Botox also is sometimes used to treat migraine.

Cluster headache and Botox
Cluster headache pain is more severe than migraine pain and can drive patients to perform desperate acts, even suicide, to avoid it. Therefore finding effective treatments for this devastating condition, which affects an estimated 53 people per 100,000 per year, is essential.

That’s why Erling Tronvik, NTNU senior consultant and researcher, along with two colleagues, are about to undertake a study of the impact of Botox on cluster headache sufferers. This team has devised a treatment device that will allow them to shoot Botox through a hole in the nasal wall into a nerve bundle located behind the sinuses.

Clinicians will use magnetic resonance imaging (MRI) scans to accurately identify the location of the nerve bundle in each patient before treatment is initiated. According to Tronvik, this unique approach should (in theory) reduce or eliminate the flow of signals in this area for three to eight months, after which time patients would need to get another treatment.

“We designed the equipment ourselves, and Botox has never been used for this anywhere else,” noted Tronvik. Soon, 10 patients will enter the first pilot study of this treatment method.

If the results of the pilot study are positive, the team plans to enroll 30 to 40 patients who suffer with cluster headache and about 80 migraineurs as well.

Are there any side effects? Tronvik explained that use of MRI is a highly accurate way to locate the exact spot to inject the Botox. However, he also noted that if the toxin were to slightly miss the mark, patients could experience a weakened ability to chew or temporary double vision.

In the meantime, there’s some good news regarding chronic migraine. Botox has been shown to be helpful in relieving chronic migraine, as seen in the results of the PREEMPT (Research Evaluating Migraine Prophylaxis Therapy) clinical program.

In that study, nearly 70 percent of patients treated with Botox experienced at least a 50 percent reduction in the frequency of headache days. Other research has shown Botox to be effective as preventive treatment for chronic migraine and to provide a reduction in severity and intensity of pain as well as the number of days with disability.

If you suffer with cluster headache, a new effective treatment can’t come soon enough. Hopefully Botox or another option in the pipeline will prove beneficial in the near future.

Study References
Alvaro-Gonzalez LC et al. Botulinum toxin A in chronic refractory migraine: premarketing experience. Revista de Neurologia 2012 Oct 1; 55(7): 385-91
Aurora SK et al. OnabotulinumtoxinA for chronic migraine: efficacy, safety, and tolerability in patients who received all five treatment cycles in the PREEMPT clinical program. Acta Neurologica Scandinavica 2014 Jan; 129(1): 61-70

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NIH and NFL will research long-term effects of concussions

This article outlines research that will be done on the long-term effects and consequences of concussions. This research will be done as a partnership between the National Institutes of Health (NIH) and the National Football League (NFL).

The U.S. National Institutes of Health is teaming up with the National Football League on research into the long-term effects of repeated head injuries and improving concussion diagnosis.

The projects will be supported largely through a $30 million donation made last year to the Foundation for the National Institutes of Health by the NFL, which is wrestling with the issue of concussions and their impact on current and former players.

There's growing concern about the potential long-term effects of repeated concussions, particularly among those most at risk, including football players and other athletes and members of the military.

Current tests can't reliably diagnosis concussion. And there's no way to predict which patients will recover quickly, suffer long-term symptoms or develop a progressive brain disease called chronic traumatic encephalopathy (CTE), according to an NIH press statement released Monday.

"We need to be able to predict which patterns of injury are rapidly reversible and which are not. This program will help researchers get closer to answering some of the important questions about concussion for our youth who play sports and their parents," Story Landis, director of the National Institute of Neurological Disorders and Stroke (NINDS), said in the news release.

Two of the projects will receive $6 million each and will focus on determining the extent of long-term changes that occur in the brain years after a head injury or after numerous concussions. They will involve researchers from NINDS, the National Institute of Child Health and Human Development and academic medical centers.

One of the projects will attempt to define a clear set of criteria for various stages of CTE. It will also seek to distinguish it from Alzheimer's disease, amyotrophic lateral sclerosis (Lou Gehrig's disease) and other degenerative brain diseases that as of now can only be determined in brain tissue samples collected after death. The objective is to find medical signs of CTE that might eventually be used to diagnose the illness in living people.

The other project will seek to identify the long-term effects of mild, moderate and severe traumatic brain injury (TBI) and compare them with features of CTE. The goal is to identify signs that could be used to diagnose brain degeneration linked to traumatic brain injury in patients.

While the two projects focus on different aspects of traumatic brain injury, "their combined results promise to answer critical questions about the chronic effects of single versus repetitive injuries on the brain, how repetitive TBI (traumatic brain injury) might lead to CTE, how commonly these changes occur in an adult population, and how CTE relates to neurodegenerative disorders like Alzheimer's disease," Landis said.

Six other pilot projects will receive a total of just over $2 million and last up to two years. They will concentrate on improving the diagnosis of concussions and identifying potential medical signs that can be used to assess a patient's recovery. If the early results are promising, these projects may form the basis of more extensive research, the news release said.

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Insomnia symptoms can raise risk of death

Both insomnia, and the symptoms of insomnia such as issues falling asleep or staying asleep, have been shown to risk a person's risk of death.

With our busy lives, it can be tempting to shrug off -- or ignore altogether -- difficulties with sleep. Trouble falling asleep, difficulty staying asleep throughout the night, waking feeling tired and unrefreshed: These are commonly experienced disruptions to sleep for millions of adults. Too often, these sleep problems aren't taken seriously, or are considered the less-than-ideal price to pay for living full and sometimes hectic lives.

Difficulty falling asleep, waking during the night, waking very early in the morning, and experiencing un-restorative sleep are all symptoms of insomnia, a serious sleep disorder. People may experience these symptoms all at once, or some of them and not others. They may experience them chronically or every so often. They are signs of disrupted, poor quality sleep and they should never be ignored.

New research indicates how high a price we may pay for overlooking signs of insomnia. Scientists at Massachusetts' Brigham & Women's Hospital have identified a link between insomnia symptoms and elevated risk of death. Their study, which included more than 23,000 men, found certain symptoms of insomnia associated with higher mortality risk from cardiovascular disease. The men were all participants in the Health Professionals' Follow-Up Study, a long-term, ongoing research endeavor that investigates issues related to men's health. In 2004, 23,447 men reported to researchers about their sleep and any insomnia symptoms. Researchers followed up with the men over a period of six years, during which time 2,025 of the men died. After adjusting for other mortality-influencing factors including age, lifestyle habits, and other health problems, researchers analyzed data on men's mortality as related to the presence of the following insomnia symptoms:

• Trouble falling asleep
• Difficulty maintaining sleep
• Waking in the early morning
• Experiencing non-restorative sleep

They found that several symptoms of insomnia were associated with higher rates of cardiovascular death among the men. In particular:

• Men who reported having difficulty falling asleep had a 55 percent increased risk of death from cardiovascular disease as compared to those men who did not experience this sleep difficulty.
• Men who reported experiencing un-refreshing sleep most of the time were at 32 percent higher risk for cardiovascular death than men who did not report this symptom.

Poor sleep is well understood to have a serious, negative impact on heart health. Not sleeping well, or enough, raises the risks for a number of cardiovascular problems, includinghigh blood pressure, heart attack, heart failure, and stroke. Protecting the quality of sleep as we age is a critical component of protecting long-term cardiovascular health.

This isn't the first scientific evidence of a link between poor sleep and increased mortality risk. But the news is particularly worrisome because these symptoms are quite common, particularly as we age. Estimates suggest that 30 percent or more of American adults experience some insomnia symptoms at least periodically, and for 10-15 percent, insomnia is chronic. Insomnia grows increasingly common with age: More than half of adults over the age of 65 experience symptoms of insomnia. Women are at higher risk than men for insomnia, due in part to hormonal cycles during childbearing years and to the hormonal changes associated with menopause. This current study included only men, but other research has shown higher risks of mortality associated with poor sleep in both men and women:

• In a number of studies that included both men and women, sleeping fewer than six hours and more than eight hours per night has been associated with increased mortality risk.
• Obstructive sleep apnea in men and in women is linked to significantly highercardiovascular and overall mortality risks. Studies have shown that mortality risksfrom cardiovascular problems are two or more times greater for adults with obstructive sleep apnea. The more severe the obstructive sleep apnea, the greater the mortality risks.
• Research has also linked use of sleeping pills to increased mortality risk. The link between higher rates of mortality and sleeping pill use exists even after factoring out other possible contributors to death risk, including health problems, age, and gender.

Ready for some good news? While sleep problems left untreated may shorten longevity, improving sleep can have powerful positive health benefits. A study conducted recently in the Netherlands found that a regular routine of 7-8 hours of sleep may have as significant an impact on risk for cardiovascular death as not smoking.Regular, sufficient amounts of high-quality sleep have also been linked to reduced risk for Type 2 diabetes, largely because of the positive effect that sleep can have on improving insulin sensitivity.

If you have symptoms of insomnia, don't ignore them. Share them with your doctor. Make an honest assessment of your sleep habits and make a commitment to taking simple steps to improve your sleep routine and your overall sleep hygiene. Taking steps to improve the quality and quantity of your sleep is one important way to protect your cardiovascular and overall health for the duration of your life. And sleeping well may actually help you extend that duration.

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Autism not related to mother's antidepressant use

A large study has shown that a mother's antidepressant use while pregnant is not linked to her child having autism.

Despite some concerns to the contrary, children whose moms used antidepressants during pregnancy do not appear to be at increased risk of autism, a large new Danish study suggests.

The results, published Dec. 19 in the New England Journal of Medicine, offer some reassurance, experts said.

There have been some hints that antidepressants called selective serotonin reuptake inhibitors (SSRIs) could be linked to autism. SSRIs are the "first-line" drug against depression, and include medications such as fluoxetine (Prozac), sertraline (Zoloft), citalopram (Celexa) and paroxetine (Paxil).

In one recent U.S. study, mothers' SSRI use during pregnancy was tied to a twofold increase in the odds that her child would have autism. A Swedish study saw a similar pattern, though the risk linked to the drugs was smaller.

But both studies included only small numbers of children who had autism and were exposed to antidepressants in the womb.

The new study is "the largest to date" to look at the issue, using records for more than 600,000 children born in Denmark, said lead researcher Anders Hviid, of the Statens Serum Institute in Copenhagen.

And overall, his team found, there was no clear link between SSRI use during pregnancy and children's autism risk.

Hviid cautioned that the finding is still based on a small number of children who had autism and prenatal exposure to an SSRI -- 52, to be exact. The researchers noted that it's not possible to rule out a small increase in autism risk.

But, Hviid said, "at this point, I do not think this potential association should feature prominently when evaluating the risks and benefits of SSRI use in pregnancy."

Commenting on the findings, Christina Chambers, director of the Center for the Promotion of Maternal Health and Infant Development at the University of California, San Diego, stated, "I think this study is reassuring."

One "important" point, Chambers added, is that the researchers factored in mothers' mental health diagnoses -- which ranged from depression to eating disorders to schizophrenia.

"How much of the risk is related to the medication, and how much is related to the underlying condition?" Chambers said. "It's hard to tease out."

In theory, she noted, depression or other mental health disorders could contribute to autism risk because those moms may be more likely to make unhealthy lifestyle choices, such as smoking or drinking.

In this study, Hviid's team did initially see a slightly increased risk of autism among children whose mothers used SSRIs during pregnancy. But once the researchers factored in the psychiatric disorders themselves, that statistical link fell away.

On top of that, there was a slight increase in autism risk among children whose mothers had used an SSRI in the two years before pregnancy, but not during pregnancy.

Hviid said that all suggests it's the underlying conditions, rather than the drugs, that are associated with a small autism risk -- though the reasons, he added, are unknown.

The study, which was funded by the Danish government, is based on records from Denmark's national system of health databases. Of nearly 627,000 children born between 1996 and 2005, just under 3,900 were later diagnosed with autism.

Among those children, 52 were born to mothers who filled an SSRI prescription during pregnancy. There were just over 6,000 other children whose mothers used the antidepressants during pregnancy but did not develop autism.

Both Hviid and Chambers said the findings do not prove that SSRIs carry no autism risk. And a connection is biologically plausible, Hviid said.

No one knows what causes autism, which affects an estimated one in 88 children. But it involves a disruption in fetal brain development. It's thought that serotonin -- the chemical that SSRIs target -- contributes to early brain development, and in animals, altered serotonin levels can affect brain function and behavior.

"It's still worthwhile to continue to study this," Chambers said.

But, she added, based on the human studies so far, "if there is any increased risk of autism, it appears small."

And for any one woman, Chambers said, that possible risk would have to be balanced against the risks of leaving major depression untreated.

"For some women, the optimal situation may be to take an SSRI, even if there is an association [with autism]," Chambers said.

Hviid agreed, saying that's a decision that has to be left up to women and their health care provider.

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Botox for depression? Turn that frown upside down...

Its a randomized, placebo controlled clinical trial...Wow! JR

J Psychiatr Res. 2013 Dec 1. pii: S0022-3956(13)00356-7. doi: 10.1016/j.jpsychires.2013.11.006. [Epub ahead of print]

Treatment of depression with onabotulinumtoxinA: A randomized, double-blind, placebo controlled trial.

Finzi E1, Rosenthal NE2.

Author information

Abstract

Converging lines of evidence suggest a role for facial expressions in the pathophysiology and treatment of mood disorders. To determine the antidepressant effect of onabotulinumtoxinA (OBA) treatment of corrugator and procerus muscles in people with major depressive disorder, we conducted a double blind, randomized, placebo-controlled trial. In an outpatient clinical research center, eighty-five subjects with DSM-IV major depression were randomized to receive either OBA (29 units for females and 40 units for males) or saline injections into corrugator and procerus frown muscles (74 subjects were entered into the analysis). Subjects were rated at screening, and 3 and 6 weeks after OBA treatment. The primary outcome measure was the response rate, as defined by ≥ 50% decrease in score on the Montgomery-Asberg Depression Rating Scale (MADRS). Response rates at 6 weeks from the date of injection were 52% and 15% in the OBA and placebo groups, respectively (Chi-Square (1) = 11.2, p < 0.001, Fisher p < 0.001). The secondary outcome measure of remission rate (MADRS score of 10 or less) was 27% with OBA and 7% with placebo (Chi-square (1) = 5.1, p < 0.02, Fisher p < 0.03). Six weeks after a single treatment, MADRS scores of subjects were reduced on average by 47% in those given OBA, and by 21% in those given placebo (Mann-Whitney U, p < 0.0005). In conclusion, a single treatment with OBA to the corrugator and procerus muscles appears to induce a significant and sustained antidepressant effect in patients with major depression.

TRIAL REGISTRATION:

clinicaltrials.gov Identifier: NCT01556971.

Copyright © 2013 Elsevier Ltd. All rights reserved.

KEYWORDS:

Antidepressant, Clinical trial, Corrugator, Depression, Double blind, OnabotulinumtoxinA

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