Trudhesa is a nasal delivery for dihydroergotamine (DHE) and is FDA approved for the acute treatment of migraine with or without aura in adults. Features include rapid onset of action, sustained pain freedom for 48 hours, and no evidence of medication overuse headache. Drawbacks include vasoconstriction making it contraindicated for those with uncontrolled high blood pressure or coronary artery disease. It can be very effective in helping a severe or prolonged migraine attack as it reaches IV concentrations in 30 minutes. It cannot be combined with a triptan in the same 24 hours and should not be used in pregnancy.
Zavzpret is a newly FDA approved nasal spray of Zavegepant, a CGRP receptor antagonist, and is for the acute treatment of migraine with or without aura in adults. It is in the same class as Ubrelvy and Nurtec-both oral CGRP receptor antagonists. The dose is 1 spray of 10 mg in 1 nostril in 24 hours. It may work faster than the oral CGRP receptor antagonists, also known as gepants, since it is delivered nasally. Side-effects include bad taste and nausea. It is expected to be available in pharmacies by July 2023.
Results from clinical trials show high efficacy rates with Qulipta. Qulipta blocks the activity of CGRP as do the injectables. We have many patients who have switched to Qulipta and are doing as well or better than the injectable CGRP mAB’s. To see if Qulipta may be a good option for you, please set up an appointment with one of our providers.
Taking a triptan, like Imitrex, and a gepant, like Ubrelvy, together has not been studied in clinical trials. However, they have different mechanisms of action and are not contraindicated to take together. The combination may work better for some individuals than taking either by itself.
There are several options for this 2-week period. One is to come into our office for a nerve block or for a Toradol injection. Another option is to go on a preventive during that 2-week period-an example would be Nurtec every other day. The best strategy is to call our office and set up an appointment to discuss treatment options to lessen your migraine burden during that wearing off period.
Elyxyb is a new oral liquid medication for the acute treatment of migraine in adults. It is an anti-inflammatory, Celecoxib, and is dosed as 120 mg in 4.8 ml (just under 1 teaspoon). Packaged as individual bottles containing 1 dose per bottle, it can be easily swallowed. As with all acute treatment medication, it will work best if taken early in the migraine attack.
Impel Pharmaceutical is developing a new nasal delivery formulation of DHE. At the present time, DHE, although highly effective for migraine, can only be delivered intravenously (IV) or intramuscularly (IM) which limits its ease of use. Importantly, DHE has not been associated with medication overuse headache (MOH) and can be used to treat MOH. In addition, many migraine attacks are associated with significant nausea so having this non-oral delivery may be a welcome addition for the rescue of a severe migraine attack in some individuals with migraine. To learn more, go to https://impelnp.com/treatments/migraine-treatment/
The injectable CGRP mAB’s including Aimovig, Ajovy, and Emgality should be stopped 5-6 months before trying to get pregnant. All have a long half-life ranging from 27-31 days and complete elimination of any medication is 5 half-lives. Until we have more data about using this category of treatment during pregnancy, it is advisable to have complete elimination before trying to conceive.