Why didn’t Aimovig, Ajovy & Emgality work for me? I thought they were supposed to be the new “miracle” injections for migraine prevention. I am frustrated-please help!

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.

To make an appointment, please call 949-861-8717.

Summer Newsletter 2019

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Summer Newsletter 2019

Orange County Migraine & Headache Center

Summer-a time to take vacation, enjoy longer days of sunshine, and a time to learn about some newly approved migraine & cluster headache treatments. This is truly an exciting time in the headache world. In recent weeks, three new treatments have received FDA approval in the United States. Emgality, one of the 3 CGRP monoclonal antibodies approved for prevention of migraine, got approved for the prevention of episodic cluster. Dr. Hutchinson will be going to Indianapolis (home of Lilly pharmaceutical) in July to learn the specifics of how to prescribe for cluster headache and will be a trained speaker to educate other health care providers.  Cluster headache patients will be able to inject Emgality just during their cluster periods unlike migraine patients who inject every month for prevention.  So, if you or someone you know has episodic cluster headaches, plan a visit at the end of July or sometime in August to get this treatment and have it on hand before your next cluster headache flare-up.

Two new treatments have received approval for migraine headache. One is called Tosymra and is a novel nasal delivery of Sumatriptan. It contains a patented membrane permeater enhancer that allows quick absorption into the nasal tissue. In fact, it has been shown to act as quickly as Sumatriptan 4 mg injectable. No needle and better tolerated than the injectable-a great option for migraine attacks associated with nausea and/or vomiting or for those attacks that have rapidly progressed and for which an oral tablet may not work quick enough to bring relief.  The other recently approved product is a device called Nerivio Migraine. It is a remote electrical modulation device placed on the arm and controlled by your smartphone. It is for the acute treatment of migraine.  Some advantages include good tolerability and non-invasiveness.  To learn more, go to www.Theranica.com.  Dr. Hutchinson will be attending an Advisory Board on July 13th in Philadelphia to learn more about this new device.

Lastly, I want to being to your attention that we offer both B-12 and B-complex injections in our office. They can address B-vitamin deficiencies as well as help energy. They can be especially helpful if you are stressed, recovering from an illness or surgery, suffer from fibromyalgia or chronic fatigue syndrome, or have absorption issues due to gastric by-pass. If you are interested in either injection, they can be scheduled as an injection visit with Aurora, our certified medical assistant (CMA).

If you are looking for updated information in the resource/handout section of our website, the following 4 handouts have been recently updated: Preventive Treatment of Migraine; Acute Treatment of Migraine; Medication Overuse Headache; and Cluster Headache. We are going to work on updating all handouts on our website. Feel free to offer suggestions you may have to improve our website and educational services to you, our patient.

Have a wonderful summer. We look forward to seeing you in our office so that we can help you be as headache-free as possible this summer.


Warm regards,

Dr. Susan Hutchinson & Dr. Molly Rossknecht

June 21, 2019

What is ergotamine? Is it better than Imitrex for acute migraine treatment?

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 am planning on getting pregnant in the next few months. What can I take for my migraine attacks once I am pregnant?

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.

To make an appointment, please call 949-861-8717.

Spring Newsletter: Spring Cleaning

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Spring Newsletter

Orange County Migraine & Headache Center

Spring is traditionally a time for “spring cleaning” and so it is for us at OC Migraine & Headache Center. Many of our patient handouts and resource materials date back to 2007. We have now begun the process of updating all materials on our website so that you have access to the most current information.  Here is a sneak preview: our first handout being revised is on the topic of cluster headache. New advances include the FDA approved GammaCore stimulator for acute and preventive treatment of cluster headache. It is a non-invasive vagal nerve stimulator. In addition, studies look very promising for one of the new CGRP monoclonal antibodies to get approval for cluster headache.

Very importantly, we are updating our web-based resources when you want information about a particular topic related to your headaches.  We have identified four in particular that we feel offer good information without being overly promotional. They are the following:

  1. American Migraine Foundation (the patient educational resource affiliated with The American Headache Society to which both Dr. Hutchinson & Dr. Molly belong)
  1. http://migraine.com (interactive website for migraine sufferers)
  2. http://migraineagain.com (trusted healthcare advice from providers around the world)
  3. National Headache Foundation (large membership base for all types of headache)


As we update and work to improve our website (www.ocmigraine.org) we welcome your feedback both positive and negative. Please address your feedback and/or suggestions for new material on our website to our office email at info@ocmigraine.og

Thank you for your trust in our headache-focused medical practice. This is truly an exciting time for headache with many new and emerging treatments both for acute and preventive. We look forward to your next appointment so we can determine which new treatments may be best for you.

Enjoy your spring-cleaning,

Dr. Susan Hutchinson & Dr. Molly Rossknecht

I am trying to get off narcotics. What are some non-narcotic treatment options to rescue me when I have a severe migraine?

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.

To make an appointment, please call 949-861-8717.

Dr. Hutchinson’s Trip To India

As many of you are aware, I was asked to go to India with a team of international headache experts to educate local providers. Each one of us on the team had a specific purpose and for me, it was to focus on the treatment of migraine in women. The need for good migraine management in India is great. With a population of over 1.3 billion, the estimated prevalence of migraine in India is over 150,000 million. By comparison, the prevalence of migraine in the United States is 38 million.

Women in India suffer from migraine disproportionally to men similar to the United States with a ratio of 3:1 beginning with puberty. To complicate the plight of women in India, many do not go for medical care without their husband or their husband’s permission.  Part of my mission was to educate the need for women to have access to medical care.

Our team did educational programs in both Delhi and Kochi, India. The audience included neurologists, primary care providers, psychiatrists, nurses, and social workers.  The next step is to help local providers in Kochi to open a Center of Excellence for Headache at The Amrita Hospital Center. This Center will offer a multi-disciplinary team to provide comprehensive care of the headache patient. Amrita Hospital is non-profit and provides care for everyone including those unable to pay.

Spending time on the streets of India, riding in a rickshaw in the very populated & crowded old Delhi marketplace, visiting Gandhi’s memorial, enjoying a boat ride on the backwaters of Kerala in southern India, and enjoying great food were all part of my experience. Perhaps the most memorable part of this trip was the incredible graciousness, hospitality, and kindness that I and the rest of the team experienced.  Several neurologists, the hospital medical director for Amrita, and the US coordinator for our efforts hosted us. I have never experienced the level of hospitality that I did in India. The hospitality and kindness was universal from hotel staff, healthcare professionals, the Rickshaw drivers, and those in the local marketplaces.

Even the poor on the street of India exhibited a kindness and gentle spirit that is not common in the United States. I return, both grateful and humbled, by this incredible experience.

I am including a few photos from my memorable trip. I look forward to seeing many of you for follow-up now that I am back in the United States.



Dr. Susan Hutchinson

Director-Orange County Migraine & Headache Center

What is the difference between Aimovig, Ajovy, and Emgality for migraine prevention?

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.

To make an appointment, please call 949-861-8717.

I have cluster headaches. Would any of the new CGRP monoclonal antibodies (CGRP mABs) work for cluster headache prevention?

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.

To make an appointment, please call 949-861-8717.

Dr. Hutchinson To Partake In India Trip To Educate Primary Care Physicians

A newly formed non-profit healthcare organization in India has asked a small team of US physicians to lead the way in educating Primary Care Physicians and neurologists about migraine. Dr. Hutchinson’s focus will be the importance of treating migraine in women including the right for women to access medical care in the face of local culture. She will be spending time in both the Delhi and Kochi locations of the 2 hospitals and out-patient clinics for Amrita Hospital International. The time frame for this trip is 2/19 to 3/25/19. She is excited about this opportunity to educate and “make a difference” in another part of the world and knows patients in our practice will be in good hands with Dr. Molly Rossknecht.