COME JOIN US! Miles for Migraine Event San Diego November 5th, 2022

The 4th Annual Miles for Migraine Event for San Diego will be at Liberty Station Park in San Diego. Our office has formed a team called OC Migraine. Please consider joining and/or supporting our team. All proceeds go to increasing migraine awareness and funding migraine research.

Dr. Susan Hutchinson is the Team Captain. We are currently at the top of the leader board for number of team numbers and amount of money raised. We truly support any level of support you can offer including joining our team & participating in this fun event, joining our team to raise money to support this worthy cause, or donating.

For those interested in participating & learning more about this event, use the following link:

https://raceroster.com/events/2022/58354/miles-for-migraine-san-diego-2022/teams

Our practice will provide and pay for a post-event brunch for all participating with our team. Options for this event include walking a 2K, running a 5K, or simply enjoying some activities at the venue while cheering on those of us running or walking. Booths featuring treatments for migraine will provide educational value to this event.

For those interested in donating to our team or to one of us as an individual, here is the link:

https://raceroster.com/events/2022/58354/miles-for-migraine-san-diego-2022/pledge/team/387564

Thank you for any level of support you may be able to provide.

For any questions, please direct those to our office website: info@ocmigraine.org

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Podcast: Dr. Hutchinson Discusses Estrogen and Migraine Controversy

This week’s episode of Heads UP is on the Estrogen and Migraine Controversy. Lindsay Weitzel, Ph.D. questions Susan Hutchinson, MD, Headache Specialist and author of The Woman’s Guide to Managing Migraine all about estrogen, migraine, aura, stroke risk, birth control, perimenopause, HRT, bioidenticals, etc.

The video version of Heads UP is available on: website, YouTube, Facebook. Download Heads UP on Apple PodcastsSpotifyStitcher, or wherever you get your podcasts.

Dr. Susan Hutchinson Contributes to “Migraine Management for the Nurse Practitioner: Acute and Preventive Therapies to Reduce Burden of Disease” Continuing Education

Dr. Susan Hutchinson has contributed to the continuing education webcast “Migraine Management for the Nurse Practitioner: Acute and Preventive Therapies to Reduce Burden of Disease”. The intended audience for this activity is nurse practitioners and other health care professionals involved in the management of patients with migraines. You can learn more by visiting https://www.mycme.com/courses/migraine-management-for-the-nurse-practitioner-8009

Ubrelvy & Reyvow Now Available

Good news…. we now have 2 new medications for the acute treatment of migraine.  Both are oral tablets and represent alternatives for those who have unmet acute migraine treatment needs. The triptans, first introduced in the United States in 1992, have been the mainstay of treatment for years. They include Imitrex, Maxalt, Zomig, Relpax, Axert, Amerge, and Frova. Most are generic and inexpensive. Are the new medications better? For some patients, they may be.

The goals for acute migraine treatment are to be headache free and back to full function in 2 hours after taking the acute medication like Imitrex. If your migraine treatment is not consistently bringing you to headache freedom in 2 hours you would be a candidate for Ubrelvy or Reyvow. In addition, if you are putting up with “triptan sensations” like neck/chest tightness, flushing, fatigue, nausea, or worsening of the headache before it gets better, you may tolerate Ubrelvy or Reyvow better. Lastly, if you have a contraindication to the triptans due to coronary artery disease, peripheral vascular disease, or multiple cardiac risk factors, these new medications would be safer as neither Reyvow nor Ubrelvy cause vasoconstriction.

Ubrelvy (Ubrogepant) is the first oral “gepant” to be FDA approved. It is an oral CGRP (calcitonin gene-related peptide) antagonist and works by blocking at the CGRP receptor site. In binding to this receptor site, it prevents the CGRP peptide that is released during migraine to attach and thereby, prevents the pathway of migraine. Numerous studies have shown that CGRP gets elevated during migraine. To learn more go to www.scienceofmigraine.com. Ubrelvy does not cause vasoconstriction, is very well tolerated in clinical trials, and so far, does not appear to cause medication overuse headache. It is available as a 50 mg & a 100 mg tablet and may be repeated in 2 hours. Ubrelvy comes in a package of 10 and for patients with commercial insurance, is available for $10 per 10 tablets per month. To learn more, go to www.Ubrelvy.com and to access the savings program, go to www.Ubrelvy.com/savings. If you are up-to-date on your visit with us, we may be willing to send in a Rx for Ubrelvy prior to your next visit. If interested, please email us at info@ocmigraine.org.

Reyvow (Lasmiditan) works differently than Ubrelvy. It is a 5-HT1F serotonin receptor agonist and is referred to as a “ditan” Reyvow binds to the 5-HT1F receptor activating it, which then inhibits pain pathways and inhibits release of neuropeptides like CGRP. It is not associated with vasoconstriction or medication overuse headache. However, it crosses into the central nervous system (CNS) and as such, can cause drowsiness and sedation. As a result, it is a controlled medication and is Schedule 5 by the DEA. Schedule 5 represents medications that have the least addictive potential. Reyvow comes as a 50 and 100 mg strength tablet and is dosed as 50 mg, 100 mg or 200 mg as a single dose in a 24-hour period. There is a driving restriction for 8 hours due to the potential sedation and dizziness seen in clinical trials.  Reyvow may be useful as a rescue option when an individual is home for the day with a moderate to severe migraine and does not plan on driving for 8 hours. As headache specialists, we are hopeful that Reyvow can take the place of Butalbital products including Fiorinal & Fioricet as well as Hydrocodone Products such as Vicodin & Norco. To learn more go to www.Reyvow.com. Reyvow has a savings program for those with commercial insurance. Using the savings program, an individual should be able to get 8 tablets per month for zero copay. Information about the savings program is available at www.Reyvow.com.  Because Reyvow is a controlled medication, please make an appointment with us if you are interested in trying. We need to carefully review the potential side effects with you.

Other medications will be coming soon including Rimegepant, another oral gepant for acute migraine. In 1-2 years, Atogepant, a 3rd oral gepant, should be available and will be for the prevention of migraine.

This is truly an exciting time in migraine. With new treatment options, comes new hope for a brighter future for all individuals with migraine.

We look forward to working with each of you to optimize your headache treatment plan.

 

Dr. Susan Hutchinson & Dr. Molly Rossknecht

February 12, 2020

Miles for Migraine Event San Diego, Saturday November 9th

Please join us for this fun walk/run event at beautiful De Anza Cove in the San Diego Area. You have the option of a 2-mile walk or a 5K or 10K Run. The event is to raise awareness of migraine and raise funds to advance migraine understanding and research.

The address for this event is 3000 Mission Bay Drive, San Diego, CA. It starts at 9 am. Race packets can be picked up the morning of the event or the afternoon before. For specific details on race packet pick-up, see the website.

Our office has formed a team called OC Migraine. Feel free to join our team in this inaugural event. For those joining our team, we will have logo shirts printed with our team name and we will gather together before and after our walk/run for photos. Dr. Hutchinson has signed up for the 10K and her office manager, Norma, the 2-mile walk.

The goal for our team is to raise $2000. Dr. Hutchinson and Norma have already made personal donations to our fund. Please join us & help us meet our goal.

To learn more about Miles for Migraine, the website is www.milesformigraine.org

If you are unable to participate but would like to donate the link is https://raceroster.com/events/2019/22686/miles-for-migraine-san-diego-2019/pledge/participant/15

Any size donation is appreciated. Please make a difference in lifting the burden of migraine!

For any questions, contact our office at 949-861-8717 or email us at info@ocmigraine.org

Sincerely,

Orange County Migraine & Headache Center

September 5, 2019

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.

Sincerely,

 

Dr. Susan Hutchinson

Director-Orange County Migraine & Headache Center

Summer Newsletter: Barometric Pressure Change & Migraine

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Many of my migraine patients tell me they don’t even need to listen to the weather report. They can tell when rainy or cloudy weather is coming due to an increase in their migraines.

Why is that?
We don’t know exactly why changes, especially drops, in barometric pressure can lead to migraines but here is what we do know: an approaching storm causes a drop in barometric pressure. This affects the pressure in the external environment including the external ear canal. This can lead to an imbalance between the pressure behind the tympanic membrane (middle ear) and the external barometric pressure. There is a certain air pressure in the sinuses, Eustachian tubes, and inner ear at any given time and if the external pressure drops, that imbalance is thought to trigger a migraine in some migraine sufferers. A change in barometric pressure of as little as .20 millibars impacts the pressure in the ear canal and can lead to migraines.

How can this be treated? 
In addition to taking the usual migraine medication, inserting a pressure regulating device (MigraineX) may be helpful. MigraineX looks like a small set of ear plugs (drug & latex free) and is designed to control the rate of barometric pressure changes in the ear canal adjacent to the ear drum (tympanic membrane). The device can be inserted preventively or at first sign of headache if a drop in barometric pressure suspected as the trigger. This product is best used in conjunction with a free App called MigraineX that can predict changes in weather and barometric pressure.

When I first learned about this device, I requested that a limited number of free samples be sent to my office for use in my patients who report that changes in barometric pressure cause migraine attacks. I have given out the first 8 devices this past week and have asked these patients to give my office feedback in coming weeks.

I am skeptical of new products that come into the marketplace promising too much especially if they are expensive. I was very pleased to see that MigraineX can be ordered online through Amazon for only $11.99. In addition, it retails for about $9.99 at CVS and does not require a prescription.

Grant O’Connell, Digital Marketing Manager, Cirrus Healthcare/MigraineX states “What separates MigraineX from other migraine relief medications is, medication-only focuses on relieving symptoms after a headache starts. The best defense against weather-related migraines is to prevent the pressure before it starts. Utilizing our app for weather event alerts will give you a step ahead to minimize the pressure using the MigraineX plugs. We are confident new customers will find MigraineX to be a great reliever from headaches.”

As I am writing this newsletter, I am wearing them and they are comfortable. They were easy to insert. Also, I easily downloaded the MigraineX app.

In a study of 36 patients who used this device in addition to their usual migraine medications, the majority felt their migraine was better treated and less likely to return. For more information, go to www.migrainex.net

For any of you who feel that changes in barometric pressure and weather are a common trigger for your migraines, I suggest you set up an appointment to review our current treatment plan and see if this new MigraineX device makes sense for you.

In summary, MigraineX may be a welcome addition to your Migraine Toolbox if changes in weather and barometric pressure are triggers for you. I welcome your feedback once you have tried this device.

 

Susan Hutchinson, MD

Director-Orange County Migraine & Headache Center

June 18, 2017

Dr. Susan Hutchinson Featured In FREE Live Online Migraine Event, Register Now!

The Migraine World Summit returns this April 23 – 29, 2017 to bring together over 30 top experts and doctors to provide answers, new treatments, research and best practices for migraine and chronic headache. It’s available to anyone with an internet connection.

Dr. Susan Hutchinson is one of the featured specialists.

 

UPDATE: Link has been removed as the event has passed.

Summer Newsletter 2014

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Three New Treatments for Chronic Migraine

Dear Patients,

The official day of summer is rapidly approaching. Longer hours of daylight, days at the beach, outdoor BBQ’s, vacations, and a break from the more structured September-May time frame is welcomed by many. But for the migraine patient, the heat of the summer months can be a frequent cause of headache exacerbation. Staying well-hydrated and avoiding being out in the middle of the day are common-sense precautions. Are there some other treatments that may prove helpful for those who dread the summer months and feel “nothing is working” for them?

In this newsletter, I would like to discuss three novel treatment approaches to consider for those frustrated with their current migraine pattern.

  1. The Cefaly Headband: this is the first medical device approved by the FDA for the prevention of migraine headaches. It is a small, portable battery-powered headband that is worn across the forehead and fits over the ears on both sides. This device applies an electric current to the skin in the center of the forehead just above the eyes. This current is similar to that of other transcutaneous electrical nerve stimulators (TENS) that have been used for years in the treatment of pain and are frequently part of physical therapy. The electrical current of the Cefaly device stimulates branches of the trigeminal nerve, which is associated with migraine headaches. There are 3 settings for the device: one for prevention of migraine; one for acute treatment of migraine; and one for relaxation. In the patient satisfaction study of 2,313 Cefaly users in France and Belgium, more than 53% of patients were satisfied with Cefaly treatment and were willing to buy the device for continued use. The device is approximately $350 and requires a prescription to purchase. So far, in my practice, about ½ of patients who have tried the device are satisfied and happy with the results so this is consistent with the findings in the patient satisfaction study.
  2. Myers Cocktail IV Treatment: this is an IV treatment containing calcium gluconate, magnesium, B-vitamins, Vitamin C, and msc. Other amino acids/electrolytes administered in an IV bag of 100 cc solution. It takes about 6 minutes to go in. It is not covered by insurance and costs just under $100 for the basic IV treatment. According to a physician colleague of mine, it is recommended as a monthly treatment for maintenance. It is available at Link Medical in Newport through Dr. Garrett Wdowin who is a Naturopath MD (NMD). The phone number to schedule an appointment and/or IV treatment is 949-465-0770. My opinion is that this IV treatment may benefit some migraine patients who are frustrated with their current treatment and this treatment appears to be quite safe.
  3. California eyeBrain Medical Trial: For some chronic daily headache patients, there may be an imbalance between the patient’s peripheral vision and central vision. This could cause overstimulation of the Trigeminal nerve and be contributing to chronic daily headache and neck pain. For patients who have chronic daily headache (headache 15 or more days a month for over 3 months) and have dry eyes, sensitivity to light, stiffness in shoulders or neck, and/or lethargy (fatigue), then you may be a candidate for a novel treatment for your headaches. There is a clinical trial to evaluate a new treatment to address imbalance between peripheral and central vision; there is no charge to be in this trial. To see if you are a candidate for this eyeBrain free clinical trial, go to http://eyebrainmedical.com/self-evaluation website and take the self evaluation of 12 questions. This should only take about 3 minutes to complete. You will then be contacted in 24 hours to determine your eligibility for this study. The treatment involves a progression or prisms in glasses to address the imbalance contributing to the frequent headaches. The study dates in Orange County are June 23-26th. I have met with the study coordinators and was pleased with their honesty and genuine interest in helping chronic daily headache patients with their approach. Their study appears to be quite safe and non-invasive; I like the fact that patients are screened ahead of time by the on-line self-evaluation. This helps to minimize wasting anyone’s time if they are not a candidate for this study. My advice: check it out and take the on-line self-evaluation; you have nothing to lose.

In summary, I have discussed three novel treatments for migraine patients. If you feel you are a candidate for any of these treatments, please call our office and set up an appointment to discuss them further. For the Cefaly headband, a prescription is required to order the device. This could be a great time to come in and have your migraine treatment plan evaluated and improved. I look forward to seeing you in my office in the near future and in the meantime, have a wonderful summer.

Sincerely,
Susan Hutchinson, MD Director-Orange County Migraine & Headache Center

Winter Newsletter 2013

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migrainebook_large

Happy New Year to all! I am happy to announce the release of my new book: The Woman’s Guide to Managing Migraine: Understanding the Hormone Connection to find Hope and Wellness. It has taken me 3 years to write this book and as with any major project, it is a wonderful feeling of accomplishment at last!

I wrote this book to help women who are looking for help with their migraines, including the hormonally driven migraines that are often the most severe. My goal is to give the reader the up-to-date knowledge and insight they need to better understand and mange their migraines. For readers who are my patients, it provides comprehensive information regarding my approach to migraine management. For others it may help to better communicate with their health care providers and receive improved migraine management. My passion to learn as much as I can about migraine diagnosis and treatment to help my patients was the driving force behind the hours and weekends I had to give up to write this book. I hope my book can help minimize the impact of migraines in your life. If the quality of your life improves, my book has served its purpose. At the end of the day, I think we all ask ourselves, “Have I made a difference?” Making a difference in your headaches and your life-that is my passion and my desire.

It has now been six years since I left family medicine to focus on headache and mood disorders in my medical practice. There are times I miss being a family physician but feel I can make a greater impact in alleviating pain (both physical and emotional) by focusing my energy and talent. As many of you may be aware, I am affiliated with Hoag Hospital. Along with Dr. Philip O’Carroll and Dr. Ali Makki, we have formed the Hoag Headache & Facial Pain Program. I still maintain my primary practice location in Irvine but am in Newport Beach at Hoag on Tuesday mornings for those patients who prefer the Newport Beach location. My affiliation with Hoag enables me to partner with Hoag’s resources. Through Hoag, we offer a free monthly headache support group (2nd Wednesday of every month from 6 pm-7:30 pm Hoag Neuroscience Board Room), community presentations, weekend symposiums, and a team approach for headache including psychologists, physical therapists, and nutritionists. My staff privileges at Hoag allow me to admit patients, when necessary, for medication overuse headache, and to arrange for IV Infusion Treatments for treatment of severe headaches.

My New Year’s Resolutions include getting my life in balance with a focus on exercise including swimming, running, and playing golf; in addition, I want to “slow down” and appreciate the day-to-day of all that life offers. What are your New Year’s Resolutions? I hope they include taking care of you and living the quality of life you deserve. If your headaches are robbing you of the quality of life you desire, then I invite you to call and make an appointment to review your headache management. New treatments for acute and prevention of headaches are available and may be an option for you. I look forward to seeing you in 2013!

Sincerely,
Susan Hutchinson, MD Director-Orange County Migraine & Headache Center

Fibromyalgia: What Is It?

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In the course of treating both migraine & depression, my patient population of fibromyalgia has grown. Fibromyalgia often co-exists with migraine and depression. If an individual has migraine headaches, that person is more likely to also have fibromyalgia than the general population. The same is true for depression. This newsletter is devoted to this disabling condition.

Fibromyalgia is a common and very disabling condition that affects 5% of women and 1.6% of men in the general population. It is considered an idiopathic disorder of chronic generalized musculoskeletal pain. The pain is in all 4 body quadrants (i.e. the whole body) as well as in specific soft-tissue tender points often called “trigger points”. A patient with fibromyalgia will be very sensitive when light pressure is applied to these trigger points, often located in the neck and upper back. Other symptoms may include fatigue, sleep disturbance, stiffness, and decreased concentration. I have also been told by some of my patients that they feel “flu like” symptoms, tingling or burning sensations or at times, achy all over.

What causes fibromyalgia? The exact cause is unknown but it appears to be from altered pain processing, creating an increased sensitivity to light touch that normally should not be painful. Similarly, migraine patients have an increased sensitivity to their environment, e.g. to changes in barometric pressure or the drop in estrogen with menses. There are striking similarities between migraine & fibromyalgia.

Treatment includes both pharmacologic and non-pharmacologic options. There are 3 FDA-approved medications for fibromyalgia. They are:

  1. Lyrica (pregabalin)
  2. Cymbalta
  3. Savella

Other medications commonly used for fibromyalgia but not FDA-approved include the following:

  1. Tricyclic Antidepressants such as Elavil and Pamelor. This class of medication has been found helpful in fibromyalgia but side-effects include sedation, dry mouth, constipation and weight gain.
  2. Selective Serotonin Reuptake Inhibitors (SSRIs) such as Prozac, Zoloft & Lexapro. This class of medication has shown mixed results in helping fibromyalgia and would not be considered first-line therapy.
  3. Selective Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) such as Effexor and Pristiq. This class of medication has shown greater effectiveness than SSRIs and includes 2 of the FDA approved drugs for fibromyalgia: Cymbalta & Savella.
  4. Anti-epileptic Drugs (AEDs) such as Neurontin (gabapentin), Lamictal (lamotrigine), Topamax (topiramate), Tegretol (carbamaxepine), and Depakote (valproate). Lyrica, the first FDA-approved medication for fibromyalgia, is in this class. This class of medication shows good benefit in reducing the pain of fibromyalgia and has established itself as potentially the most effective class of medication for migraine prevention. Two of the medications in this class, Topamax and Depakote, are FDA-approved for migraine prevention.Non-pharmacologic treatment includes cognitive behavioral therapy, biofeedback, acupuncture, physical therapy, chiropractic care, and structured exercise programs. Many fibromyalgia patients claim they are “too tired” to exercise. One study showed benefit in exercising for just 10 minutes several times a day. I encourage all my patients to exercise as much as they are able to.Vitamin, herbal and nutritional supplementation may help. The B vitamins are known to be important in stressful conditions and can increase energy. I offer both B-complex & B-12 injections in my office which can potentially boost energy and help lessen the fatigue associated with fibromyalgia. In some cases I recommend a full vitamin & mineral blood panel called SpectraCell which can identify nutritional deficiencies that can be contributing to fatigue and pain. Once the deficiencies are identified, the patient can be instructed on which supplements are needed. I am presently consulting with a local chiropractor, Dr. Di Siena, who offers an integrative program known as First Line Therapy to help patients optimize their well-being from chronic conditions like fibromyalgia.Promising new treatment includes transcranial magnetic stimulation (TMS). This is done in an out-patient setting, is safe & non-painful, is done in a series of treatments, and has been found to be helpful in treatment resistant depression, anxiety and fibromyalgia. Another new treatment is low dose naltrexone. Naltrexone is a medication that has been used clinically for >30 years to treat opioid addiction. More recently, it has been tested in several clinical trials for fibromyalgia and showed a 30% improvement in symptoms compared to placebo. In addition, it was very well tolerated in these studies and is relatively inexpensive.In summary, fibromyalgia can be a very disabling and frustrating medical condition. However, a good integrative approach that combines traditional pharmacological treatment and non-pharmacologic treatment can be very beneficial even for the most difficult-to-treat patient. I believe that the best treatment for a patient is the one that gives them the greatest relief. I encourage you to set up an appointment to develop a treatment plan that can help you live the quality of life you deserve.Sincerely,
    Susan Hutchinson, MD Director-Orange County Migraine & Headache Center

Botox and Headache Prevention

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Many of my headache patients ask if Botox would help their headaches. This newsletter will focus on Botox and its role in headache prevention. A patient testimonial will be included. I hope this newsletter will help you decide if Botox makes sense for you.

What is Botox?
Botox is Botulinum Toxin Type A. It is a neurotoxin used for greater than 20 years and is currently FDA approved for eye muscle conditions such as strabismus and blepharospasm and for a neck problem called cervical dystonia. The mechanism of action for these conditions is related to the muscle relaxing properties of Botox. It is not yet FDA approved for migraine or headache prevention; however recent clinical trials show promising results. Two recently completed clinical trials were done exploring the use of Botox for adults suffering from “chronic migraine”, i.e. headaches and/or migraine occurring on 15 or more days/month. The results of these 2 studies showed a decrease in the number of headache and migraine days. Additionally, the quality of life in patients receiving Botox in the studies improved significantly compared to patients receiving placebo injections.

For complete product and prescribing information, go to www.botox.com.

How is Botox injected for headache prevention?
Typically 100 units of Botox are injected in multiple sites over the forehead; around the eyes; the temples; the back of the neck and the upper back. The Botox comes in a 100 unit vial and I mix it with a saline solution prior to injection, yielding a concentration of 2.5 units per .1 cc. Then, I fill 5 small syringes, each containing 20 units of Botox. Very small 30 gauge needles are attached to the syringes and then the Botox is injected. There are certain fixed sites and amounts that I use for every headache patient and these include the forehead; the eye and the temples. The fixed sites require 65 units of Botox. With the remaining 35 units, I can “follow the pain” of where my patients experience most of their pain relative to their headaches and tailor the remaining Botox injections accordingly.

The vial of Botox is mixed fresh for each injection visit. There is no “sharing” of Botox with other patients. Each patient pays for and receives the equivalent of 1 full vial of Botox (100 units). Studies indicate that larger amounts (100-300 units) are required for headache prevention in contrast to cosmetic uses of Botox which often require much less quantity.

What are the risks of Botox injection?
The risks are minimal and include bruising, swelling and pain at the site of injection. There is a very slight risk of eyelid dropping which is reversible. An ice pack is applied prior to the forehead and facial injections which can lessen injection pain and prevent bruising and swelling.

To learn more specifics re: benefits/risks of Botox, click on www.imigraine.net.

How soon does it work?
From my experience, many patients feel almost immediate relief from the muscle tenderness part of their headaches, including the forehead, neck and upper back areas. This is due to the muscle relaxing characteristics of Botox. However, true migraine prevention results are not often evident for 2 weeks. The accepted theory on why Botox works to prevent migraine is that it prevents the release of some of the inflammatory agents that cause migraine such as CGRP and substance P.

How long does it last?
Most patients experience 12-14 weeks of benefit after Botox injection. Many comment they can tell when it starts wearing off by an increase in headache.

What is the cost?
Currently we charge a total of $825.00 for Botox injection. This fee includes 1 full vial of Botox (100 units); all related supplies such as needles and syringes; and the procedure cost. The time for the procedure is 30 minutes. In most cases, you can return to work after your injection.

Our policy is to offer insurance billing for Botox; however, we cannot guarantee it will be covered since it is not FDA-approved for headache prevention and is considered “experimental” and “off-label” by most insurance companies.

Patient Testimonial (a quote from one of Dr. Hutchinson’s patients)
“I am really pleased with the results! I felt a “softening” of the muscle tension in my forehead and the back of my neck right away and that has continued over the past week. As you indicated, it appears that the injections take some time to fully work. My forehead today feels better than it did over the weekend, and my shoulders and neck have not been as tense either. I am very satisfied with the results and feel that Botox can be another “weapon” in my arsenal to prevent migraines.”

How do I know if I am a good candidate for Botox for headache prevention?
If you are currently frustrated with your headaches, then Botox is a strong consideration. It is especially helpful, in my opinion, for those patients who have a muscle tension component to their headache, e.g. a lot of forehead/scalp or neck muscle tightness and tenderness. Also, based on the recent studies by Allergan (the maker of Botox), those with more frequent headaches, especially more than 15 days/month, would be good candidates for Botox injection for headache prevention.

Please call our office 949-861-8717 and set up an office visit to evaluate whether you would be a good candidate for Botox. I will review your current headache management as well as the pattern of your headaches and give you my opinion. If Botox makes sense, it can be ordered and the injections given 1-2 weeks later.

Sincerely,
Susan Hutchinson, MD Director-Orange County Migraine & Headache Center

New Treatment for Migraine

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The FDA just approved a new medication for the acute treatment of migraine. It is called Treximet and is a combination of Imitrex (a migraine specific medication) and Naproxen (an NSAID: Nonsteroidal anti-inflammatory medication). Treximet is the first drug of its kind on the market and represents an advancement in the acute treatment of migraine. It is now available in pharmacies.

Why was this combination brought to market?

To answer this question we need to look at what occurs during a migraine attack. Migraine is a neurovascular event and involves the release of neurochemical transmitters such as CGRP and Substance P. These neurotransmitters cause inflammation and vasodilation of blood vessels surrounding our brain. The triptans (Imitrex; Relpax; Maxalt; Axert; Zomig; Frova; Amerge) prevent the release of these neurotransmitters and in turn, prevents the involvement of the blood vessels. They are most effective in taken early in this process.

We have now discovered another pathway involved in migraine that consists of the production and release of prostaglandin. The NSAIDs (nonsteroidal anti-inflammatory medications) inhibit prostaglandin production and release and include medications such as Motrin, Aleve, Advil, and Naprosyn.

Therefore, it makes sense to combine these 2 drugs to attack the multiple pathways involved in migraine. The combination should potentially be more effective than either agent alone.

Why not just take an OTC NSAID like Aleve or Advil with a triptan?

Taking the NSAID such as Aleve with the triptan may not be as effective. From extensive research studies and clinical trials, a unique pharmacokinetic profile is seen with the combination tablet. The Imitrex portion of the tablet reaches peak levels quickly, providing important initial relief; the Naproxen component of the tablet is delayed and reaches peak levels of concentration later than if given separately. This delayed release of the Naproxen provides the important headache prevention needed as the Imitrex begins wearing off. Therefore, most patients experience initial headache relief within 1-2 hours followed by sustained pain-free results for 24 hours.

Additionally, the combination tablet is convenient and eliminates the need to carry two separate medication bottles. Treximet will be packaged in a quantity of #9 tablets and is in a small container that will easily fit into a woman’s purse, e.g.

Who should not take Treximet?

Anyone who has established coronary or peripheral vascular disease should not take Treimet which contains Imitrex, a triptan medication. If an individual has cardiac risk factors such as high blood pressure of high cholesterol, they should be screened prior to triptan use. Anyone with a history of an allergic reaction of any of the triptan medications should not take Treximet. Anyone with a history of an allergy or contraindication to NSAIDs such avoid the use of Treximet which contains Naproxen, a NSAID. Contraindications would also include gastric ulcer; gastritis/esophagitis; history of gastric by-pass; and someone on Coumadin or other blood thinners. Pregnant women should avoid the use of Treximet. Full prescribing information is available at www.treximet.com.

How do I know if I should switch to Treximet? Answer these migraine treatment questions.*

  1. Do you want more relief from your migraine medicine?
  2. Do you ever need more than one dose of your current medicine to treat your migraines?
  3. Do you ever take more than one medication to relieve a single migraine attack?

If your answer was “yes” to 1 or more of these questions, then you may benefit from Treximet. It may provide more complete relief for your migraine headaches. In addition, you may be less likely to re-dose or rescue compared to your current acute headache treatment. Complete relief of head pain and associated symptoms such as nausea within a 2 hour time period is a reasonable expectation followed by sustained pain free for at least 24 hours.

*Migraine Treatment Questionnaire developed by GlaxoSmithKline Pharmaceutical and recognized by the National Headache Foundation as an effective way to initiate dialogue between healthcare professionals and patients regarding treatment effectiveness. Printed with permission from GSK Pharmaceutical.

How do I know if Treximet better than my current triptan or other acute headache medication? Answer the following questions.

  1. Are you headache free in 2 hours and back to full function?
  2. Are there any side-effects on the medication?
  3. Do you need to re-dose within 24 hours?
  4. Do you have to rescue with another medication?
  5. Does the headache stay away completely for at least 24 hours? (Sustained pain-free)

In summary, Treximet is the newest prescription medication on the market for the acute treatment of migraine with or without aura in adults 18 and older. The combination of Imitrex/Naprosyn represents the most migraine specific medication now available. Schedule an appointment with Dr. Hutchinson or your primary care provider to see if Treximet would be right for you.

Sincerely,
Susan Hutchinson, MD Director-Orange County Migraine & Headache Center