Image credit: Wellcome Images, Wellcome Library, London, via Wikimedia Commons.
Last week I gave a quick overview of standard treatment options for migraine, a severe form of recurrent headaches. As promised, this week I will address some common treatments for migraine that I don’t think are supported by the evidence.
Acupuncture is the CAM modality that, it seems to me, has infiltrated the furthest into mainstream medicine, including for the treatment of migraine. In fact the The American Headache Society includes acupuncture on its list of recommended treatments. The reason for this is that acupuncture proponents have been able to change the rules of clinical research so that essentially negative or worthless studies of acupuncture are presented as positive.
I reviewed the evidence for acupuncture and migraine previously, demonstrating the multiple problems with the acupuncture literature in general, and specifically acupuncture in migraines. Most studies suffer from at least one fatal flaw: they are not properly blinded, they do not include a control, they mix acupuncture with non-acupuncture variables (mostly including electrical stimulation in the treatment group), comparison groups are not adequately treated, they make multiple comparisons to maximize chance outcomes, or they are simply too small making them susceptible to all the usual problems of bias in research.
What we don’t see is a consistent and clinically-relevant effect in properly-controlled double-blind trials where the variables of acupuncture are isolated.
I am a headache specialist and so I receive many questions, through SBM, NeuroLogica or listeners of the Skeptic’s Guide to the Universe, about how to best treat headaches, or about a specific, often unusual, treatment. Migraines and severe headaches are very common. According to the latest statistics:
14.2% of US adults 18 or older reported having migraine or severe headache in the previous 3 months in the 2012 NHIS. The overall age-adjusted 3-month prevalence of migraine in females was 19.1% and in males 9.0%, but varied substantially depending on age. The prevalence of migraine was highest in females 18-44, where the 3-month prevalence of migraine or severe headache was 23.5%.
That means about 28 million Americans suffer from migraines. Percentages do vary from continent to continent, but not dramatically. Migraine, therefore, is a huge burden. Headaches can be debilitating when severe, and so also are a major source of lost productivity.
This will be a two-part series reviewing some of the options for treating migraines, focusing on science-based treatments in part I, and non-science-based treatments in part II. None of this is intended to give specific medical advice for any individual. If you have severe headaches you should consult your physician. I will simply be reviewing the evidence for various options, focusing on migraine specifically.
Caffeine, a common trigger for migraines and headaches
A new study published in JAMA sheds further light on a controversial question – whether or not to prescribe low-dose aspirin (81-100mg) for the primary prevention of vascular disease (strokes and heart attacks).
Primary prevention means preventing a negative medical outcome prior to the onset of disease, in this case preventing the first heart attack or stroke. Secondary prevention refers to treatments given to patients who have already had their first heart attack or stroke in order to reduce the risk of subsequent events.
The evidence strongly supports the efficacy of aspirin for the secondary prevention of both heart attacks and strokes. Aspirin has two effects which likely contribute to this protective effect. First, aspirin is an anti-platelet agent – it reduces the stickiness of platelets, which are cell fragments in the blood that clump together to stop bleeding. They can also clump together around an ulcerated cholesterol plaque on an artery, forming a thrombus, resulting in blockage or embolus (the clot traveling downstream) and causing either a heart attack or stroke.
Other anti-platelet agents, such as clopidogrel, are also effective in preventing stroke and heart attack.
Of course, platelets exist for a reason, and blocking their action increases the risk of bleeding or can make bleeding worse when it occurs. Therefore determining the optimal dose and target population are important to maximize the benefit of aspirin or other anti-platelet agent while minimizing the bleeding risk. (more…)
Case reports are perhaps the weakest form of medical evidence. They are essentially well-documented anecdotes. They do serve a useful purpose, however. They can illuminate possible correlations, the natural course of illness and treatment, and serve as cautionary tales regarding possible mistakes, risks and complications. I say “possible” because they are useful mainly for generating hypotheses and not testing or confirming hypotheses.
Dramatic case reports, however, with objective outcomes, like death, can be very useful by themselves in pointing out a potential risk that should be avoided. For example, case reports of objective and severe adverse outcomes are often used as sufficient evidence for pulling approved drugs off the market, or at least adding black box warnings.
The chiropractic community, it seems, does not respond in a similar way to dramatic adverse events that suggest possible risk from chiropractic manipulation. A recent and unfortunate case raises once again the specter of stroke following chiropractic neck manipulation. Jeremy Youngblood was 30 years old, completely healthy, and saw his chiropractic for some neck pain. According to news reports, Jeremy suffered a stroke in his chiropractor’s office while being treated with neck manipulation for the neck pain. According to reports the chiropractor did not call 911, but instead called Jeremy’s father who had to come and pick him up and then bring him to the ER. Jeremy suffered from a major stroke and later died.
Gayle DeLong has been diagnosed with what she refers to as “autism-induced breast cancer”. She’s even given it an abbreviation, AIBC. Unfortunately, as you might be able to tell by the name she’s given her breast cancer, she is also showing signs of falling into the same errors in thinking with respect to her breast cancer as she clearly has with respect to autism. As a breast cancer surgeon, regardless of my personal opinion of DeLong’s anti-vaccine beliefs, I can only hope that she comes to her senses and undergoes science-based treatment, but I fear she will not, as you will see. Her brief post announcing her diagnosis and blaming it on autism, however, does provide what I like to call a “teachable moment” about cancer.
We’ve met DeLong before on this blog. For instance, she published an execrably bad study that—of course!—tried to link vaccine to autism and failed miserably, despite doing some amazing contortions of analysis, combining diagnoses willy-nilly, all in the service of the discredited vaccine-autism hypothesis. As I said at the time, it just goes to show that someone who is an associate professor of economics and finance shouldn’t be doing epidemiological research. As I also described at the time, if the sorts of analytical techniques she used in her study are acceptable in the world of economics and finance, no wonder our economy has been so screwed up for so long. Another time, DeLong wrote a broadside against the regulatory machinery that oversees vaccine development and safety that was full of the usual antivaccine misinformation, tropes, and pseudoscience and hugely exaggerated perceived “conflicts of interest” among the various parties.
The Courage to Heal, the source of many beliefs about false memory syndrome
It is disheartening that we have to return to pseudosciences that have been debunked decades ago, because they continue to linger despite being eviscerated by scientific scrutiny. Belief systems and myths have incredible cultural inertia, and they are difficult to eradicate completely. That is why belief in astrology, while in the minority, persists.
Professions, however, should be different. A healing profession should be held to a certain minimum standard of care, and that standard should be based upon something real, which means that scientific evidence needs to be brought to bear. Professionals are not excused for persisting in false beliefs that have long been discredited.
The 1980s saw the peak of an idea that was never based on science, the notion that people can suppress memories of traumatic events, and those repressed memories can manifest as seemingly unconnected mental health issues, such as anxiety or eating disorders. The idea was popularized mostly by the book The Courage to Heal (the 20th anniversary edition was published in 2008), in which the authors took the position that clients, especially women, who have any problem should be encouraged to recover memories of abuse, and if such memories can be dredged up, they are real.
[Ed. Note: I realize that I normally post on Monday, but thanks to an R21 grant deadline tomorrow, I will not be able to post new material today (although you might have noticed some “familiar” material posted yesterday.) Harriet has graciously agreed to cover for me today, and we have a special guest post for you tomorrow. Fear not. I’ll soon be back. Trying to get the lab funded takes momentary precedence.]
In his new book The Myth of Mirror Neurons: The Real Neuroscience of Communication and Cognition , Gregory Hickok, a professor of cognitive science, challenges current conceptions about mirror neurons. He shows how a complex mythology arose and why it is unwarranted, how experimental results were misinterpreted and disconfirming evidence ignored, and how other interpretations might lead to better insights about how the brain works.
I couldn’t say it any better than Steven Pinker did on the jacket blurb:
Every now and again an idea from science escapes from the lab and takes on a life of its own as an explanation for all mysteries, a validation of our deepest yearnings, and irresistible bait for journalists and humanities scholars…Hickok puts an end to this monkey business by showing that mirror neurons do not, in fact, explain language, empathy, society, and world peace. But this is not a negative exposé—the reader of this book will learn a great deal of the contemporary sciences of language, mind, and brain, and will find that the reality is more exciting than the mythology. (more…)
The antivaccine movement and conspiracy theories go together like beer and Buffalo wings, except that neither are as good as, yes, beer and Buffalo wings. (Maybe it’s more like manure and compost.) In any case, the antivaccine movement is rife with conspiracy theories. I’ve heard and written about more than I can remember right now, and I’m under no illusion that I’ve heard anywhere near all of them. Indeed, it seems that every month I see a new one.
There is, however, a granddaddy of conspiracy theories among antivaccinationists, or, as it’s been called, the central conspiracy theory of the antivaccine movement. That conspiracy theory postulates that “they” (in the U.S, the CDC) have known for a long time that vaccines cause autism, but “they” are covering it up. In other words, the CDC has, according to this conspiracy theory, been intentionally hiding and suppressing evidence that antivaccinationists were right all along and vaccines do cause autism. Never mind what the science really says (that vaccines do work don’t cause autism)! To the antivaccine contingent, that science is “fraudulent” and the CDC knew it! Why do you think that the antivaccine movement, in particular Robert F. Kennedy, Jr., went full mental jacket when Poul Thorsen was accused of financial shenanigans (i.e., fraud) with grant money from the federal government? It was a perfect story to distract from the inconvenient lack of science supporting the antivaccine view that vaccines cause autism. More importantly, from the antivaccine standpoint, it was seen as “validation” that the CDC studies failing to find a link between autism and vaccines were either fraudulent or incompetently performed. Why? Because Thorsen was co-investigator on a couple of the key studies that failed to find a link between the MMR and autism, antivaccinationists thought that his apparent financial fraud must mean that he committed scientific fraud. They’re the same thing, right? Well, not really. There were a lot of co-investigators, and Thorsen was only a middle author on those studies.
As the time came to do my usual weekly post for this blog, I was torn over what to write about. Regular readers might have noticed that a certain dubious cancer doctor about whom I’ve written twice before has been agitating in the comments for me to pay attention to him, after having sent more e-mails to me and various deans at my medical school “challenging” me to publish a link to his results and threatening to go to the local press to see if he can drum up interest in this “battle.” I’ve been assiduously ignoring him, but over time the irritation factor made me want to tell him, “Be very careful what you ask for. You might just get it.” Then I’d make this week’s post about him, even though I wasn’t thrilled with the idea of giving in to his harassment and giving him what he wants.
That’s why I have to thank the ever-intrepid investigative reporter Brian Deer for providing me an alternative topic that is way more important than some self-important little quack and a compelling topic to blog about in its own right. Brian Deer, as you might recall, remains the one journalist who was able to crack the facade of seeming scientific legitimacy built up by antivaccine guru Andrew Wakefield and demonstrate that (1) Wakefield’s work concluding that the MMR vaccine was associated with “autistic enterocolitis” was bought and paid for by a solicitor named Richard Barr, who represented British parents looking to sue vaccine manufacturers, to the tune of over £400,000; (2) Wakefield expected to make over £72 million a year selling a test for which Wakefield had filed a patent application in March 1995 claiming that “Crohn’s disease or ulcerative colitis may be diagnosed by detecting measles virus in bowel tissue, bowel products or body fluids”; and Wakefield’s case series published in The Lancet in 1998 was fraudulent, the equivalent of what Deer correctly characterized as “Piltdown medicine.” Ultimately, these revelations led to Wakefield’s being completely discredited to the point where The Lancet retracted his paper and even Thoughtful House, the autism quackery clinic in Austin, TX where Wakefield had a cushy, well-paid position as scientific director, had to give him the boot. Yes, Wakefield is a fraud, and it’s only a shame that it took over a decade for it to be demonstrated.
As much as I hate how it took discrediting Wakefield the man as a fraud rather than just discrediting his bogus science to really begin to turn the tide against the annoying propensity of journalists to look to Wakefield or his acolytes for “equal time” and “balance” whenever stories about autism and vaccines reared their ugly heads, I can’t argue with the results. Wakefield is well and truly discredited now, so much so that, as I noted, his prominent involvement probably ruined any chance promoters of the “CDC whistleblower” scam ever had to get any traction from the mainstream press.
What is sometimes forgotten is the effect Wakefield’s message has had on parents. These are the sorts of parents who tend to congregate into groups designed to promote the idea that vaccines are dangerous and cause autism, such as the bloggers at the antivaccine crank blog Age of Autism, the equally cranky blog The Thinking Moms’ Revolution, or groups like The Canary Party. It is Wakefield’s message and the “autism biomed” quackery that it spawned that have led to unknown numbers of autistic children being subjected to the rankest form of quackery in order to “recover” them, up to and including dubious stem cell therapies and bleach enemas.
Ed. Note: Today we present a guest post from Josh Cuevas, a cognitive psychologist and assistant professor in the College of Education at the University of North Georgia. Enjoy!
Breaking the cycle
Since early on in graduate school when I began studying cognition, I’ve followed the learning styles movement because it was such a powerful phenomenon. It took hold rapidly, seemingly overnight, at all levels of education. And, like so many fads in education and science, it created a big-money industry involving conferences, training seminars, paid speakers, how-to manuals, and a variety of other mediums, inevitably linked to a profit in some way. Yet in the peer reviewed studies I was sifting through, evidence for learning styles was nowhere to be found. And more than a decade later I’m still looking for it.
Today when I suggest to students that learning styles are no more than a myth, I can hear their collective jaws drop, regardless of whether they’re undergraduates or graduate students, because learning styles have been preached to them the entire time they’ve been in school. The graduate students concern me the most because they’re supposed to know the research. And I used the term “preached” because these students have been convinced via no more than word of mouth, are asked to accept the information based on faith, and many come to hold a strange religious-like fervor for the concept. That’s not how science works and it shouldn’t be how education works.
It has been no easy task combating this common misconception in college classrooms, particularly when it is reinforced in textbooks, by other professors (who are also supposed to know the research), and in public schools where students do their internships. The research we’re doing at the University of North Georgia on learning styles has two purposes – it allows us to collect data on the effects of learning styles and contrast it to a stronger model, dual coding, but it also lets us demonstrate, in real time, to students who will one day be teachers how what they’ve long believed to be true simply does not work when put to the test. (more…)