Toradol is a non-steroidal anti-inflammatory medication and is part of the category commonly referred to as the “NSAIDs”. Other examples of NSAIDs include Motrin, Ibuprofen, Cambia, Aleve, Naprosyn, and Diclofenac, and Celebrex. The generic name for Toradol is Ketorolac. It can be given orally, intramuscular, intravenously, or nasally. In its oral form, there is no evidence that it works any better than the oral NSAIDs. However, when given non-oral as an injection, nasal delivery, or IV, it works faster and has better bioavailability. We commonly offer Toradol 60 mg IM in our office as a way to rescue a prolonged or severe migraine. Unlike a narcotic or Benadryl injection, it does not cause sedation so a patient can safely drive home after receiving the Toradol injection. Studies at Harvard by Dr. Rami Burstein have shown that a migraine can progress to a stage in which oral triptans will not work but injectable Toradol can work. To determine if Toradol in any of its forms would be an appropriate addition to your migraine “toolbox” please set up an appointment at our office.
Nerivio is a non-invasive neurostimulator device that has received FDA approval for the acute treatment of migraine in adults. The device is wrapped around the upper arm similar to a blood pressure cuff. It is turned on and the intensity is adjusted via an app on a smart phone device. There are no wires or cords so a patient can be hands free to go about their normal activity while the headache is being treated. The recommended treatment period is 45 minutes for a migraine attack. The expected time frame for availability is October 2019. We are one of a limited number of headache centers in the United States that will have demo units for patients to try in our office. It is anticipated that the first month of treatment will be free. It is very exciting to have a new non-invasive treatment option for migraine. To learn more go to https://theranica.com
In the clinical trials with all three CGRP injections (Aimovig, Ajovy, Emgality) patients had to be off Botox for 4 months before receiving CGRP injections. This exclusion was not due to safety concerns; rather, the trials were designed to see how well migraines would respond to CGRP by itself or with an oral preventive and not while still receiving Botox. One of the concerns is that insurance companies may not approve both. Both are relatively expensive treatments. We have patients in our practice who are doing both but we are encouraging them to try CGRP by itself at some point as CGRP injections may work so well for migraine prevention that Botox is not needed. Fortunately, there are wonderful savings programs for all 3 CGRP injections for commercial insurance patients so now is a good time to set up an appointment and see what preventive regimen best for your migraines.
I am sorry this new category did not work for you. I hope you had an adequate trial for each one which would be a minimum of 3-6 months. All 3 of the CGRP monoclonal antibody injections currently FDA approved for migraine prevention target CGRP, a neuropeptide released throughout the peripheral and central nervous system during migraine attacks. Significantly, these large molecules given via injection only work on the peripheral nervous system. There is a new oral CGRP category coming out that are called “gepants”. These “gepants” in development for acute and preventive treatment of migraine are small molecules and will be able to cross the blood brain barrior and work centrally as well as peripherally. They could potentially be more effective for some migraine patients. In addition, there is another neuropeptide called PACAP that appears to be a key player in migraine pathophysiology. There are drugs in development to target PACAP and perhaps for some migraine patients, targeting PACAP may be more effective than targeting CGRP. Don’t give up-there are new drugs in development.
Ergotamine is in a group of drugs called the ergot alkaloids and has been available for many years for the acute treatment of migraine & cluster headache attacks. It acts by constricting blood vessels. Some forms of ergotamine tablets are combined with caffeine, e.g. Cafergot, and others are ergotamine by itself, e.g. Ergomar sublingual tablets. This category of acute headache medication should not be used in patients with coronary artery disease, peripheral vascular disease, high blood pressure, or in pregnancy or breast-feeding. Side-effects include elevation in heart rate & blood pressure, shakiness, and peripheral coldness in hand & feet due to the vasoconstriction. Ergomar comes in as a sublingual tablet so can be convenient for those with nausea and/or needing fast relief. The 2 mg tablet gets placed under the tongue where it dissolves; the dose can be repeated every 30 minutes to maximum of 3 tablets in 24 hours. For some patients, ergotamine may work better than Imitrex or other triptans. If you are interested in seeing if ergotamine is appropriate for your headaches, please call our office to make an appointment.
I advise you come in for an office visit prior to getting pregnant to review your current medications. There may be some like Topamax (Topiramate) that you should wean off prior to getting pregnant. Others like Sumatriptan, Ibuprofen, and Zofran are OK to take while trying to get pregnant but need careful consideration once pregnant. Safe options during pregnancy include Tylenol, caffeine in moderation, Diclegis for nausea, Sumatriptan in moderation, and the 3 neurostimulators including the Cefaly device, SpringTMS, and GammaCore. For rescue of a severe migraine during pregnancy, we can do an occipital nerve block in the office with Bupivacaine, a topical anesthetic. In a few cases, our office has injected Botox for pregnant women with refractory migraines. Fortunately, the majority of women experience improvement in their migraines during pregnancy.
This is a great question. Narcotics are not a recommended way to rescue a severe migraine. They can cause sedation, constipation, addiction, and can cause medication overuse headache. In addition, an accidental overdose can cause respiratory depression & death. Non-narcotic options can include coming in to our office for a Toradol (Ketorolac) injection, nerve blocks, and/or a trial with one of the 3 neurostimulators we have in our office including the GammaCore, the SpringTMS, and the Cefaly device. Home rescue may include injectable Sumatriptan, nasal delivery of Sumatriptan, Zolmitriptan, or Ketorolac (name brand Sprix), and/or a course of steroids. For some of our patients, a standing order set to go in to the Hoag Infusion Center in Irvine or Newport Beach is an option and can avoid having to go the ER. Consider making an appointment with us to review non-narcotic rescue options. We can work with you to customize a plan that will work for you.
All three drugs are part of a category called CGRP monoclonal antibodies and represent the first migraine specific preventive category to come to the US market. All show good efficacy and tolerability in clinical trials. All are only for adults 18 and over. None have been studied for safety in pregnancy & breast-feeding. Aimovig targets the CGRP receptor and both Ajovy & Emgality target the CGRP ligand to prevent migraine. The main difference is in dosing and administration. Aimovig is given as either a 70 or 140 mg monthly subcutaneous injection and comes as an auto-injector. Ajovy is dosed as 225 mg monthly or 675 mg quarterly subcutaneous injection and comes as a prefilled syringe with a small needle. Emgality is given as a loading dose of 2 injections of 120 mg each then a monthly 120 mg dose. Like Aimovig, Emgality comes as an auto-injector. All three are designed for self-injection at home. Aimovig and Ajovy can be injected in the thigh, abdomen, or upper arm. Emgality has an additional injection site of the buttocks. All three should be disposed of in a Sharps Container. Lastly, all three can be injected as part of an office visit if you feel you are a candidate.
Currently the only FDA approved indication for the CGRP mAB’s is for migraine prevention in adults. However, studies are underway for cluster headache prevention and the results look promising. In particular, Lilly recently completed a cluster headache trial with Emgality. For more details, go to https://migraineagain.com/emgality-cluster-migraine/ Non-CGRP treatment options include the relatively new GammaCore device. GammaCore is FDA approved for acute cluster headache treatment as well as an adjunctive treatment for cluster prevention. We have the device in our office and can arrange for a demonstration as part of an office visit.
CBD (cannabidiol) is one of several cannabinoids found in marijuana and hemp plants. CBD is not psychoactive and has low abuse potential compared to THC that is psychoactive and can cause someone to get “high”. CBD has been used to treat anxiety, insomnia, headaches, and seizures. It is felt to have anti-inflammatory properties. Typically it is dispensed as oil that can be put under the tongue or can be mixed or infused in a number of ways. Significantly, The FDA approved Epidiolex, a CBD-based drug, to treat certain forms of epileptic seizures. The FDA, National Institutes of Health, and the World Health Organization, all feel more research and testing are needed. In short, CBD may help your migraines but it is not FDA approved for migraine treatment. For more information, go to www.uspainfoundation.org, www.TheMintLeaf.org, and www.projectCBD.org