Reyvow is a new migraine medication FDA approved for acute migraine treatment. Another name for it is Lasmiditan. Although FDA approved, it cannot be prescribed until the DEA decides what category to put it in as it can cause dizziness and sedation. There will be some sort of warning on not driving for a certain number of hours after taking. Despite the sedation & dizziness as possible side-effects, it does not cause any vasoconstriction like the triptans and may be useful for patients who cannot take the triptans due to cardiac issues and for those for whom the triptans are ineffective or poorly tolerated. We expect Reyvow to be available by February 2020.
Ubrogepant is an oral tablet for the acute treatment of migraine. It targets the calcitonin gene related peptide (CGRP) receptor and prevents CGRP from binding. This blocks the migraine process. Unlike the current monthly anti-CGRP injections, this is for acute migraine treatment. It may be a great option for those dissatisfied with their current acute treatment. Ubrogepant will be an oral tablet 50 or 100 mg and can be repeated in 2 hours for a migraine attack. Unlike Reyvow, another new migraine medication, Ubrogepant does not cause drowsiness or dizziness. We think it will be available by January 2020.
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.