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.
To make an appointment, please call 949-861-8717.
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:
- American Migraine Foundation (the patient educational resource affiliated with The American Headache Society to which both Dr. Hutchinson & Dr. Molly belong)
http://americanmigrainefoundation.org
- http://migraine.com (interactive website for migraine sufferers)
- http://migraineagain.com (trusted healthcare advice from providers around the world)
- National Headache Foundation (large membership base for all types of headache)
www.headaches.org
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
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.
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.
Sincerely,
Dr. Susan Hutchinson
Director-Orange County Migraine & Headache Center
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.
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.
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.
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
To make an appointment, please call 949-861-8717.
Winter Newsletter: Major policy changes regarding Opioid and Narcotic prescribing at OCM&HC
We hope all of you are having a wonderful start to your Holiday Season. This has been a very exciting year for migraine sufferers with the launch of three Calcitonin gene-related peptide (CGRP) antibodies for migraine prevention. Aimovig was released in May. Both Ajovy and Emgality were released in September. This is the first category of migraine prevention that was developed specifically for migraine. Many of our patients are already seeing significant improvement with a reduction in both migraine frequency and severity.
For acute migraine treatment, there are oral CGRP antagonists in development. In addition, non-invasive neurostimulators are available for acute and prevention treatment of migraine and cluster. They include the Cefaly device, the SpringTMS (transcranial magnetic stimulation), and the GammaCore (non-invasive vagal nerve stimulator).
With so many specific migraine treatments emerging, our office has revisited the issue of narcotic and opioid prescribing for migraine. Narcotics like hydrocodone are not FDA approved for acute or preventive treatment of migraine or cluster headache. In addition, they can lead to medication overuse headache which can cause other treatments to not work as well. Lastly, they can cause drowsiness, depression, and can cause death in the case of an overdose.
The state of California is strictly monitoring the prescribing of narcotics and opioids. Responsible prescribing includes random urine drug screening, contracts, and limits on how many pills can be prescribed at one time. We have decided there are too many current restrictions and future restrictions for our office to prescribe any amount of narcotics. We are not pain specialists nor do we wish to be. Therefore, as of January 2019, we will be a “narcotics free” office. No exceptions will be made. All of you currently receiving a narcotic prescription from our office will receive a letter as well as a list of pain specialty practices in the local area. We will help with your transition to a pain specialist for future narcotic prescriptions. For those of you only needing a small amount of a narcotic to rescue a severe migraine, you may be able to request from your primary care provider (PCP).
There is an abundance of non-narcotic ways to treat a severe migraine attack including a Toradol injection, occipital nerve blocks, standing orders at the Hoag Infusion Center for IV medications and IV fluids, sphenopalatine ganglion blocks (SPG’s) administered in our office, a course of steroids, and anti-nausea injections or suppositories. In addition, the new CGRP monoclonal antibodies have helped some of our patients to not need a narcotic as their migraines are so much better.
We encourage you to make an appointment to come in and review your migraine plan. This is an exciting time for migraine sufferers with all the new treatments available. Let’s work together to help you be as headache-free as possible in 2019.
Happy Holiday Season,
Dr. Susan Hutchinson and Dr. Molly Rossknecht
Staff