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.
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
There have not been any studies comparing Ajovy with Aimovig. This new category of CGRP monoclonal antibodies is an incredible break-through for migraine prevention. Experience in the “real world” apart from clinical trials may help us answer your question. Significantly, both Aimovig and Ajovy have favorable side-effect profiles, are well-tolerated, and quite effective (as early as 1 week in some patients) in clinical trials.
Some patients may feel one works better than another just like some patients prefer Sumatriptan to Rizatriptan vs others prefer Rizatriptan to Sumatriptan. Treatment needs to be individualized to each patient. We are here to help develop your individualized migraine treatment plan.
Yes, there is evidence that high energy (HEV) blue wave or “blue light” that flickers from our electronic devices can aggravate migraines. This “blue light” can disrupt our sleep patterns at night, can cause eye strain, and cause oxidative stress all of which are associated with migraine. Treatment includes avoiding use of these devices for 3-4 hours before bedtime, wearing blue light blocking glasses while using these devices, and installing blue light blocking screens.
CGRP stands for Calcitonin Gene-Related Peptide. It is a neuropeptide located in neurons (nerve cells) and smooth muscle throughout the part of the nervous system that is part of the migraine process. When a migraine trigger occurs in a susceptible individual, CGRP levels increase and this increase is felt to be major part of the pathophysiology of migraine. Research has demonstrated elevated CGRP during migraine attacks. In addition, research has demonstrated relief of a migraine attack when a CGRP blocking medication is given. This blocking of CGRP is the mechanism of action of the new category of CGRP Monoclonal Antibodies that are now coming to market for the prevention of migraine. The first one available, Aimovig, blocks CGRP activity at the receptor site. To learn more, go to www.Aimovig.com and www.scienceofmigraine.com
To find out if this new preventive treatment makes sense for you, please schedule a visit at our office. We are very excited about this new treatment.
The new category of CGRP Monoclonal Antibodies for migraine prevention is ideally suited for anyone suffering from migraine at least 4 days per month. The first one is now available and is called Aimovig. It is approved for adults 18 and over. It is not recommended in women who are breast-feeding or pregnant. Most likely insurance companies will require failure or intolerance of at least 2 standard oral migraine preventives. The best next step would be to come in for an appointment so we can determine if Aimovig would be a good next step for you.
Increasing evidence from research shows that narcotics can worsen a headache condition by causing narcotic/opioid hypersensitivity. This means that over a period of time no acute medication will work as well. Narcotics are not migraine specific and are not FDA approved for the treatment of migraine. There are migraine-specific medications, oral and non-oral, that are much more appropriate for the treatment of an acute migraine attack such as the triptan category.
There can be many reasons for worsening of a headache pattern during winter months. Weather changes can be a factor, especially drops in barometric pressure that can occur before a storm. Turning heaters on can be a trigger if dust or mold has accumulated in the air ducts. For some, Holiday stress can be a trigger either from travel or entertaining. Also, there is a tendency to fall off your exercise program, not eat as healthy, and not have a consistent sleep schedule during the Holidays. Now that the Holidays are over, resuming a healthy life style should help.
Yes, they are not uncommon. Typical symptoms include visual symptoms (flashing lights, zig-zag lines, or the absence of vision in all or part of the visual field). Other symptoms can include tingling on one side of the body and/or slurred speech, or vertigo. These types of migraines are often referred to as aura without headache (acephalgic migraine). Symptoms may last from minutes to days. Treatment varies but may include migraine specific medication. These symptoms should always be evaluated by a healthcare provider for a correct diagnosis.
In the past, neurologists were the most common type of doctor that patients would see for severe headaches. Now, headache has become a specialty open to non-neurologists as well as neurologists. Currently, there are only a little over 500 headache specialists in the United States. Dr. Susan Hutchinson is a Board Certified Family Medicine Physician with a sub-specialty in headache. I am a neurologist who completed a full 1 year headache fellowship. Dr. Hutchinson’s 21 years of practicing general family medicine including women’s health can help in recognizing the important role of hormones to headache and she is especially well-suited to treat menstrual migraine. My background as a neurologist is well-suited to recognizing neurological conditions that may be associated with migraine. Together, our practice provides an excellent comprehensive approach to the headache patient.
Medications don’t work the same for everyone. Your genes can influence the way your body responds to certain medications. The good news is that gene testing is now available and can be as simple as a cheek swab that’s used to collect cells that contain your DNA. We have begun using this technology to assist in optimal medication prescribing to better suit the individual patient.