Tension headaches are a nearly universal affliction. They are characterized by dull, non-pulsatile discomfort on both sides of the temples and forehead. They typically last for 30-60 minutes, but they can go on for days. Tension headaches affect at least 40% of adults in any given year. Nearly 80% of adults have experienced at least one during the course of their lifetimes.

It’s amazing therefore, that scientists don’t yet understand what causes them.

www.youtube.com/watch?v=SuL7z6zzhYc

Triggers
To be sure, scientists and those who’ve experienced tension headaches know when they tend to occur and what things trigger them.

Tension headaches occur most commonly in the early morning and late afternoon. The morning variety is often triggered by lack of sleep, awkward sleeping positions, hangovers and caffeine withdrawal.

Afternoon tension headaches are triggered by poor posture or airborne irritants in the office, eyestrain from looking at a computer screen all day, teeth grinding, and plain-old everyday stress (see YouTube video, above). The hypoglycemia associated with missed lunches is another culprit, as is excessive caffeine intake.

But What Causes Them?
This is what scientists don’t yet understand. For years, the prevailing theory was that muscle tension, especially in the neck and shoulders, caused tension headaches. That theory has been disproven by studies in which tools that measure muscle contractions revealed no correlation between muscle tension and headaches.

Today, the prevailing belief is that the tension-type headache is caused by abnormalities in parts of the brain that perceive pain. These poorly understood abnormalities render the brain hypersensitive to the inputs it receives (similar mechanisms are also thought to be involved in fibromyalgia, a disorder characterized by diffuse bodily sensations of pain).

Treatment
Typically, tension headaches sufferers just “bear with them” until they subside, or use OTC pain killers like aspirin, acetaminophen and ibuprofen for quick relief. These drugs usually work, but taking them more than 10 days per month can precipitate so-called “rebound” or “medication-overuse” headaches, which feel like the tension headaches they’re supposed to treat.

Tricyclic antidepressants like imipramine and amitriptyline appear to prevent tension-type headaches in people who get them frequently. They are effective in much lower doses than what is required to treat depression. Even in these lower doses however, tricyclics are associated with side effects like drowsiness and dizziness. Other drugs like muscle relaxants, anti-epileptic drugs and even anti-migraine drugs have been used to prevent tension headaches.

There also is some evidence that regular aerobic exercise, a sensible diet (including less caffeine and alcohol), yoga, massage, biofeedback and acupuncture can be effective. 

Could it be Cancer?
Well, nearly ¾ of brain tumors present with symptoms similar to those of a tension headache. Then again, only about one in 200 patients who present to physicians for the evaluation of a headache are found to have a tumor.

That said, folks who have a chronic headache, frequent headaches, and headaches associated with neurological symptoms should see their doctors. The same applies for those who haven’t had success controlling their headaches with an occasional OTC pain reliever and the lifestyle changes mentioned above, and those who are worried about, or simply want more information about their headaches.

That’s what physicians are there for!

Nicotine replacement therapy makes it easier to quit smoking by providing a therapeutically safe fix of the chemical that makes cigarettes addictive in the first place. In the 25+ years since nicotine-laced patches, gum and lozenges became available, they have amassed a remarkable safety record. In fact thousands of people—and perhaps many more than that–have used NRT products for decades with few or no untoward effects (other than a notably thinned-out wallet). 

As a result, the FDA may soon relax the warning label verbiage affixed to NRT products. Currently, the FDA recommends that such products should be used for no longer than 12-weeks. The recommendation under consideration is that NRTs can be used for prolonged periods—perhaps indefinitely.

“There really doesn’t appear to be any great harm” with the use of NRT over long periods of time, said K. Michael Cummings, chair of the department of health behavior at the Roswell Park Cancer Institute in an interview. “You’re better off chewing gum or wearing a patch than smoking.”

Public health advocates like Cummings have petitioned the FDA for years to relax its recommendations. They received a boost from a 2009 law which empowered the FDA for the first time to regulate tobacco products. A provision in the law tasks the agency to consider relaxing the warning labels on NRT products.

Labels on NRT products advise users to taper-off on their consumption of the products over a 12-week period. These recommendations have stood since the FDA first approved nicotine gum in 1984. They were established to be consistent with the duration of NRT product utilization during clinical trials that were designed to test their efficacy, rather than scientific data regarding health risks associated with long-term NRT use.

There is no evidence that nicotine is carcinogenic in its own right, at least in humans. It may however increase cardiovascular risk because it causes mild tachycardia and mild elevations in blood pressure.

If the FDA does relax its warnings, it will have followed a precedent set by the British Royal College of Physicians, which concluded 4 years ago that “medicinal nicotine is a very safe drug,” and “there are no grounds to suspect appreciable long-term adverse effects on health.” Regulatory authorities in the UK, Japan, Germany and Canada have already approved NRT product use periods between 6 and 12 months.

Glaxo markets the industry-leading product, the Nicorette brand of gum, patches and lozenges. It collects a lion’s share of an $800 million US market for NRT products. Pfizer and Novartis also play in the space.

Vaccine makers won a big victory last week when the Supreme Court ruled by a 6-2 margin that US law effectively protects them from product-liability suits based on claims of poor vaccine design.

The plaintiffs in the case were the parents of Hanna Bruesewitz, who in 1992 received a diphtheria, tetanus and pertussis (DPT) vaccine and subsequently developed a seizure disorder and multiple neurological problems.

The vaccine was made by Wyeth, which was later acquired by Pfizer. Bruesewitz will require expensive medical care for the remainder of her life.

Wyeth had denied that its DPT vaccine caused Bruesewitz’ injuries and warned that an adverse ruling by the Court would presage a flood of similar lawsuits that could threaten the supply chain for childhood vaccines. The Justice Department had supported Wyeth’s position on the matter.

In its ruling, the Supreme Court upheld a decision made by the Court of Federal Claims. In the former case, the Federal Claims court rejected the Bruesewitz’ attempt to receive compensation for medical costs associated with the care of their child. In that ruling, the court argued the parents did not prove that Wyeth’s vaccine caused their child’s injuries.

(The Federal Claims Court, a.k.a. the “vaccine court, was created by the National Childhood Vaccine Injury Act of 1986. Its adjudicates vaccine-injury claims and oversees an associated national compensation program. The vaccine court has awarded nearly $2 billion for vaccine injury claims in 2,500 cases since its inception. Its funds are derived from a tax on vaccines. The Vaccine Injury Act also protects vaccine makers from certain kinds of claims.)

In writing for the majority, Supreme Court Justice Antonin Scalia said the Vaccine Injury Act “pre-empts all design-defect claims against vaccine manufacturers brought by plaintiffs who seek compensation for injury or death caused by vaccine side effects.”

Pfizer’s general counsel, Amy Schulman was pleased with the decision. The 1986 vaccine law “appropriately places the responsibility for determining the optimal design of life-saving childhood vaccines in the hands of expert federal agencies, not a patchwork of state tort systems,” she said in a press release.

The 2 dissenters were Justice Sonia Sotomayor, Justice Ruth Bader Ginsburg. They argued that the court imposed “its own bare policy preference over the considered judgment of Congress.”

Note that the Supreme Court’s decision still leaves open the possibility that plaintiffs can sue vaccine makers on issues other than vaccine design. These would include improper manufacturing techniques, for example.

People affected by a rare, inherited form of dwarfism virtually never get diabetes or cancer, scientists have reported. Their findings may someday open up new ways to treat or prevent both conditions.

The scientists are Jaime Guevara-Aguirre, an Ecuadorean physician, and Valter Longo, a cell biologist from USC. They collaborated to study a cohort of about 100 Ecuadoreans that had Laron syndrome, an extremely rare condition caused by a gene mutation that prevents their bodies from responding properly to growth hormone.

Guevara-Aguirre had been following the cohort for more than 2 decades. He and Longo reviewed his notes and found exactly one nonfatal case of cancer and zero cases of diabetes. By comparison, the scientists’ review of 1,600 relatives, who also resided in Ecuador, revealed that 5% of them developed diabetes and 17% developed cancer. These incidence rates matched those found in the general population.

The absence of diabetes was particularly remarkable since the Laron cohort had higher obesity rates than their non-affected relatives, and obesity is a risk factor for the disease.

To figure out why Laron dwarfs almost never got diabetes or cancer, the scientists performed genetic analyses on samples of their blood and saliva. They found that family members with the condition had lower levels of IGF-1 (insulin-like growth factor 1), a chemical that plays a central role in growth during childhood. Laron patients also had lower blood insulin levels and increased sensitivity to insulin.

In their write-up, the scientists hypothesized that low levels of IGF-1 and insulin could have reduced oxidative damage to DNA. Similar phenomena increase life expectancy in worms, yeast and mice, the scientists said. However, they could not conclude that this was the correct explanation for the observed low rates of cancer and diabetes.

If their hypothesis proves to be correct, it suggests that dietary- or drug-based strategies could be used to tackle the diseases. IGF-1 levels are known to fall in people who fast, or restrict protein intake for several days, for example.

Of course these dietary strategies are fraught with risks, but a drug that reduces the effects of growth-hormone (once a person is fully grown) might hold promise.

As it turns out, Pfizer’s Somavert does just this. The drug is now used to treat acromegaly and gigantism. Longo has approached Pfizer to explore the possibility of sponsoring clinical trials to test this drug for the new applications mentioned above.

Sad Side Note: Although the Laron dwarfs in this study never got cancer or diabetes, they did not outlive their relatives. It turns out that substance abuse and accidents are endemic in that community, and they end-up being an unfortunate equalizer when it comes to life expectancy.

Panic attacks are characterized by a racing heart, copious sweating, rapid breathing and feelings of impending doom and loss of control. Approximately 15% of adults have experienced a panic attack. A stressful event like a final exam or a big presentation typically precipitates the episode.

A minority of affected people, perhaps as many as 2% of adults, have full-blown panic disorder, which is characterized by frequent attacks, often in the absence of an obvious trigger, and by behaviors designed to avoid situations that might precipitate an attack. In extreme cases, affected individuals shut-out social interactions altogether to avoid the possibility that they might have a panic attack.

Physicians tend to reserve drugs like SSRIs (newer antidepressants) and sedatives to prevent recurrent panic attacks, but the drugs seem to work in no more than two-thirds of affected individuals, at best. As an alternative, many clinicians use cognitive-behavioral therapy to treat the symptoms of panic attacks. In this approach, individuals learn to control and live with that horrible sense of doom during an attack. When behavioral therapy works, people gain confidence that the unpleasant sensations are temporary and not overly harmful.

What’s New
For decades, a cornerstone of the behavioral approach to panic disorder has involved breathing deeply, usually into a paper bag. This exercise is thought to help people calm down by focusing on something benign, non-threatening and controllable.

Now, a pair of studies by Alicia Meuret and colleagues at SMU suggests that the exact opposite approach to breathing, one that involves taking slow, shallow breaths, may be better.

Meuret’s group tested a ginned-up version of “slower, shallower breaths” in which patients adjusted their breathing to correspond with a series of tones produced by an audiotape, and checked their physiological responses with a gadget called a capnometer.

The capnometer allows users to monitor carbon dioxide and oxygen levels in their blood. If the shallow breathing technique is done properly, the capnometer reveals that the patient has raised his or her carbon dioxide level. This seems to calm-down patients and gives them a sense of self-efficacy just when they need it most.

In the first study of the new technique, Meuret’s group showed that subjects increased their carbon dioxide levels and reduced the severity of panic disorder symptoms when compared to a control group. The beneficial effects were sustained for a full year following the course of therapy.

The group’s more recent study showed the new technique to be more effective than another commonly used behavioral technique in mitigating panic symptoms. The results were published in September in the Journal of Consulting and Clinical Psychology.

“It makes perfect sense, the lay suggestion that says take a deep breath,” Meuret said in an interview. But the impact of such advice is hyperventilation, or “overbreathing.” This causes carbon dioxide levels to fall and that exacerbates symptoms of anxiety and panic.

Meuret’s novel approach requires further validation, and its long-term effects need to be assessed as well. And of course, it remains to be seen whether patients can apply the technique without using a capnometer, an expensive device normally reserved for use in hospitals.

Scientists have proven that dietary fiber lowers the risk of coronary artery disease, diabetes and certain cancers. Surprisingly however, they had yet to show that fiber could impact overall mortality. Now apparently, they have done just that. 

A research team led by Yikyung Park of the National Cancer Institute has published a study showing that high fiber intake is indeed associated with longer survival.

To reach these conclusions, Park’s group looked at data from nearly 400,000 men and women between the ages of 50 and 71 using the AARP Diet and Health Study. They assessed dietary fiber intake with a questionnaire that had been administered at the beginning of the 9-year study. They excluded people with diabetes, heart disease and most cancers, as well as those who reported extremely high daily fiber intake.

After controlling for smoking, exercise and body weight, the researchers showed that dietary fiber intake was associated with a reduced risk of death in both sexes.

Specifically, people in the highest quintile for fiber consumption (29.4 grams per day for men and 25.8 grams for women) were 22% less likely to die from all causes than those in the lowest quintile (12.6 grams per day for men and 10.8 for women). Women were 34-59%, and men were 24-56%  less likely to die from heart, respiratory and infectious diseases, in particular. Fiber consumption was associated with a lower risk of dying from cancer in men (who are prone to get cancers thought to be reduced by dietary fiber intake) but not in women.

Interestingly, the type of fiber consumed made a huge difference in this study. Participants who consumed fiber from grains, like oatmeal, brown rice and cornmeal experienced all the benefits. In this study at least, fiber derived from vegetables, fruits and beans did not reduce mortality.

“Whole grains are rich sources of fiber, but also good sources of vitamins, minerals, and other phytochemicals that may provide health benefits,” Park explained in an interview. It’s also true that grains have anti-inflammatory and antioxidant properties, which could have been decisive. (It’s important to add that many prior studies have shown that diets rich in fiber from fruits and vegetables can reduce cardiovascular risk.)

The mechanisms by which fiber cuts mortality risk remain unclear. In addition to its anti-inflammatory and antioxidant effects, fiber reduces LDL (bad) cholesterol and normalizes blood glucose levels. It may also bind to cancer-causing agents in the gut, thereby preventing them from being absorbed into the body.

Note: The federal government’s new Dietary Guidelines for Americans suggest that women consume 25 grams of fiber per day, and that men consume 38 grams per day. The average American consumes about 15 grams per day. Given what appears to be differential effects of fiber from different sources, it’s wise to get your fiber from as wide a variety of sources as possible, including fruits, vegetables, grains and legumes.

The study appears in the Archives of Internal Medicine.

Genetic factors predispose people to alcoholism. That’s why the children of alcoholics are four times more likely to develop drinking problems, and the sons of alcoholic fathers are at even greater risk. And that’s why kids who are born to alcoholic parents and then raised by non-drinking parents have the same risk for alcoholism as if they had been raised by their biologic parents.

This is not to say that one, or even a handful of genes are responsible for the disease. The number is clearly far higher than that. Genes that predispose to alcoholism affect diverse physiological functions ranging from those involved with alcohol metabolism to those governing the behavioral response to rewards and pleasure. Some genes linked primarily to depression have even been linked to alcoholism.

The explanation for this multi-gene etiology is that diverse social and environmental factors can interact with genetically programmed mechanisms in complex ways, all of which end-up precipitating the syndrome.

Gene Links to Alcoholism: A Sampler
The “Asian Flush” genes are perhaps the best understood in this regard. Fully one third of all people of East Asian descent are born with a genetic deficiency that causes their cheeks, and often their necks, arms and trunk to turn sunburn-red after consuming even small amounts of alcohol. This “Asian Flush” syndrome is often associated with nausea, headache and tachycardia, distasteful symptoms which act collectively to deter people from drinking alcohol. The result: very few affected individuals become alcoholics.

A separate, colloquially named “tipsy gene” makes affected individuals feel completely bombed after just a drink or two. As many as 20% of the US population has the tipsy gene. It too seems to protect people from becoming alcoholics.

By contrast, a gene variant for the DRD2 dopamine receptor in the brain causes people to feel downright euphoric after drinking, probably because it alters the way the brain’s reward circuits respond to alcohol. Some (but not all) studies have shown this gene variant to be present in a disproportionate number of alcoholics, drug addicts and cigarette smokers.

Where This is Headed
The breakthrough concept that dozens of genes are linked to alcoholism has fostered the idea that multiple, gene-specific drugs can be deployed to fight the disease. Moving beyond the one-drug-fits all paradigm will likely lead to more effective therapy and improved compliance, or so goes the theory.

Scientists have already made progress in this regard. For example, Bankole Johnson and colleagues at the University of Virginia recently identified a cohort of alcoholics that shared a certain gene variation involving serotonin, a neurotransmitter in the brain. They prescribed ondansetron (Zofran) for these patients. Ondansetron is a serotonin blocker that is normally used to treat chemotherapy-related nausea. Remarkably, the drug reduced alcohol consumption in alcoholics with one specific gene variation, but not in those with other types of gene variations involving serotonin. 

Similarly, scientists have shown that alcohol-dependent patients with a certain gene variation for an opioid receptor in the brain had sustained, positive outcomes when treated with the drug naltrexone. Patients with different genetic abnormalities didn’t have the same positive response to the opioid blocking drug.

“Imagine this scenario,” Johnson said in an interview. “You go to your doctor and say, ‘I’m drinking and I need help. The doctor (performs) a blood test and if you qualify, you get tablets the next day and they’re likely to be effective. If you do not qualify, you don’t waste your time with the medicine.”

Cool stuff.

After nearly a decade of inaction, the US government is finally going to set safety standards for perchlorate in the nation’s water supply.

Perchlorate is a rocket fuel additive that causes thyroid abnormalities in newborns and children. Even tiny amounts of perchlorate can impair thyroid hormone production, especially in utero and in newborns. The resulting metabolic abnormalities can lead to irreversible loss of IQ and increased perceptual and behavioral problems.

Nearly all the perchlorate found in drinking water is the result of lax disposal methods at chemical plants, rocket test sites and military installations. Government estimates say that 16 million Americans are exposed to unsafe levels of the chemical. Independent scientists using state and federal data suggest the number is twice that.

White House and Pentagon officials, primarily in the Bush administration, had pressured the Environmental Protection Agency for years to refrain from establishing safe, allowable levels of the chemical in tap water, presumably because the cost of a national cleanup would cost several hundred million dollars.

But under new management (the Obama Administration), the EPA has announced it will establish standards for the toxic compound sometime during the next 2 years.

“As improved standards are developed and put in place, clean water technology innovators have an opportunity to create cutting edge solutions that will strengthen health protections and spark economic growth,” EPA administrator Lisa Jackson said in a press release.

As far back as 2002, an EPA risk assessment determined that safe levels of perchlorate in drinking water should be set at 1 part per billion. After 6 years of complete non-action on the matter, the Bush administration decided not to regulate the chemical. Instead, it established an “advisory guideline” that perchlorate concentrations should not exceed 15 parts per billion.

The delays and eventual inaction by the Bush administration were driven by the Defense Department. A GAO report published last year revealed levels in excess of the advised limit of 15 parts per billion at 53 Defense Department installations.

“Most of their sites were contaminated with perchlorate—there’s been a lot of interference by DOD in terms of stopping EPA from doing anything,” Mae Wu, an attorney with the Natural Resources Defense Council said in an interview. “They want the limit to be as high as possible so they won’t have to clean up.”

Extra Credit: At the time of the perchlorate announcement, the EPA also said it planned to establish new limits for 16 other chemicals in drinking water. Included on the list is chromium 6, or hexavalent chromium. Movie buffs will recall, that’s the compound made famous by the 2000 Oscar-winning movie, Erin Brockovich, in which title character eventually forced Pacific Gas & Electric to compensate the residents of a town that had been contaminated with the substance.

The pathophysiology of cancer involves uncontrolled cellular proliferation–that we know–but the process doesn’t go on forever. After reaching a certain size, tumors do stop growing. This phenomenon is probably driven by growth-inhibiting chemicals that are released by tumor cells themselves.

Scientists are now trying to harness this phenomenon using a decidedly counterintuitive strategy: introducing cancer cells into the bodies of mammals–including humans–that are already afflicted with cancer. The strategy amounts to fighting cancer with cancer. Remarkably, early results from studies of the technique have been positive.

The technique was developed by Barry Smith and colleagues at the Rogosin Institute, an independent treatment and research center in New York. Smith’s group creates pea-sized beads of mouse kidney cancer cells that are encapsulated in a growth-restricting shell.

Initially, the beads contain about 150,000 cancer cells. During an incubation period however, all but 1% of those cells die, according to Smith. The remaining ones secrete proteins or peptides that inhibit tumor growth. Some of the chemicals promote cell death directly; others impair a cell’s ability to stimulate new blood vessel formation which is  needed for cellular survival.

“They reach a stable state in which there is cell division and cell death,” Smith said in an interview. “They are producing inhibitory factors that regulate their growth.”

Once the encapsulated concoction is “mature” in this way, Smith’s group  implants the beads into the abdominal cavities of cancer patients.

In a pair of studies released last week in Cancer Research, Smith’s group reported that their treatment reduced tumor size in laboratory mice, dogs and cats. Many cancer-stricken animals survived longer than expected.

Smith’s team observed that mice who received the beads had tumors that were 30-60% smaller than untreated mice. In subsequent experiments with dogs and cats, the bead treatments were associated with survival rates that were longer than expected. A cohort of 11 dogs with prostate cancer experienced a median survival of 177 days, for example. They had been expected to survive less than 50 days. In some cases, the tumors disappeared almost completely. These studies did not feature a control group however, and it is far from clear that the findings will be reproduced in humans.

Smith’s group has indeed carried out an initial study in which 30 human patients received the beads. The study revealed the beads to be safe: there were no adverse effects in patients receiving the treatment. Now, a phase two trial is underway in patients with advanced cancers of the prostate, pancreas and colon.

The medical literature is filled with experimental cancer treatments that worked in animals, but flamed-out in human trials. Hopefully that won’t happen with Smith’s cancer beads.

Smallpox killed between 300–500 million people during the 20th century. As recently as 1967, 15 million people were infected and 2 million died from smallpox. Amazingly however, a massive, global vaccine-based effort to eradicate the disease was declared a complete success in 1979. That feat stands among the greatest achievements in the history of medicine. In fact to this day, smallpox remains the only human disease to have been completely eliminated from the face of the earth.

End of story, right?

Well, not exactly. Today, officials believe that the only samples of the virus in existence are stored in refrigerators at the CDC and in a Russian government lab in Siberia. At these tightly guarded facilities, scientists use the specimens to develop treatments which would be used in the event that very bad people somehow found a way to release the virus into a world containing billions of unvaccinated people.

For this to happen, bioterrorists would have to secure unsanctioned samples of the virus (none of which are known to exist), steal it from the above-mentioned facilities, or genetically engineer it (a task believed to be extremely difficult using current technology, since the virus’ genome is long and complex). It’s also possible that the above-mentioned facilities could release the virus accidentally.

The probability that any of these events will happen is exceedingly small, so public officials have debated for decades whether the known, remaining samples of smallpox virus should be destroyed.

The debate now appears headed for a resolution. Representatives of 34 countries including the US and Russia are meeting to decide the matter. The group will make recommendations to a governing body, the World Health Assembly, in March. The Assembly plans to decide the matter in May.

US and Russian officials believe the sanctioned samples should not be destroyed. They say that despite the ongoing research, scientists have yet to develop effective treatments for people who have been exposed to smallpox virus. They also argue that the virus’ unique ability to elude the human immune system constitutes an important learning opportunity. Ongoing study of the way smallpox does it could drive development of drugs that could treat many conditions in addition to smallpox.

Many developing nations, who were the ones most recently affected by the virus, will likely oppose the US position. A paper that makes the scientific case for destroying all sanctioned stocks of the virus  appears here. There are also political overtones to the debate, which are eerily similar to those which plague international efforts to stem global warming and nuclear proliferation.

“It is the same logic by which the superpowers continue the possession of the nuclear weapons,” explained Indian virologist Kalyan Banerjee to the Wall Street Journal. “They wish to hold on to the smallpox virus as a super bio-weapon.”

By the way, the US government has stockpiled more than 300 million doses of smallpox vaccine, enough to inoculate every citizen in the country. Few other countries can afford to have done that. I say keep the stocks, because I don’t know what I don’t know about the chance some bad person has a smallpox cache somewhere. I’d rather protect against the catastrophic downside risk of such an event, and review existing safeguards for the known samples. Stay tuned.