Zavzpret is a newly FDA approved nasal spray of Zavegepant, a CGRP receptor antagonist, and is for the acute treatment of migraine with or without aura in adults. It is in the same class as Ubrelvy and Nurtec-both oral CGRP receptor antagonists. The dose is 1 spray of 10 mg in 1 nostril in 24 hours. It may work faster than the oral CGRP receptor antagonists, also known as gepants, since it is delivered nasally. Side-effects include bad taste and nausea. It is expected to be available in pharmacies by July 2023.
Results from clinical trials show high efficacy rates with Qulipta. Qulipta blocks the activity of CGRP as do the injectables. We have many patients who have switched to Qulipta and are doing as well or better than the injectable CGRP mAB’s. To see if Qulipta may be a good option for you, please set up an appointment with one of our providers.
Taking a triptan, like Imitrex, and a gepant, like Ubrelvy, together has not been studied in clinical trials. However, they have different mechanisms of action and are not contraindicated to take together. The combination may work better for some individuals than taking either by itself.
There are several options for this 2-week period. One is to come into our office for a nerve block or for a Toradol injection. Another option is to go on a preventive during that 2-week period-an example would be Nurtec every other day. The best strategy is to call our office and set up an appointment to discuss treatment options to lessen your migraine burden during that wearing off period.
Elyxyb is a new oral liquid medication for the acute treatment of migraine in adults. It is an anti-inflammatory, Celecoxib, and is dosed as 120 mg in 4.8 ml (just under 1 teaspoon). Packaged as individual bottles containing 1 dose per bottle, it can be easily swallowed. As with all acute treatment medication, it will work best if taken early in the migraine attack.
Impel Pharmaceutical is developing a new nasal delivery formulation of DHE. At the present time, DHE, although highly effective for migraine, can only be delivered intravenously (IV) or intramuscularly (IM) which limits its ease of use. Importantly, DHE has not been associated with medication overuse headache (MOH) and can be used to treat MOH. In addition, many migraine attacks are associated with significant nausea so having this non-oral delivery may be a welcome addition for the rescue of a severe migraine attack in some individuals with migraine. To learn more, go to https://impelnp.com/treatments/migraine-treatment/
The injectable CGRP mAB’s including Aimovig, Ajovy, and Emgality should be stopped 5-6 months before trying to get pregnant. All have a long half-life ranging from 27-31 days and complete elimination of any medication is 5 half-lives. Until we have more data about using this category of treatment during pregnancy, it is advisable to have complete elimination before trying to conceive.
FDA approval is a more rigorous process and is required for any prescription medication brought to the market for use in the US. For example: for a new acute medication for the treatment of migraine (examples Ubrelvy, Nurtec, and Reyvow)-efficacy that is statistically significant over placebo has to be demonstrated. Safety also has to be proven in long-term safety trials. In comparison, devices such as Cefaly and Nerivio only need FDA clearance to be available for use in the US. The standards for getting FDA clearance are not as rigorous. These devices have to demonstrate a good safety profile but the requirements for efficacy over placebo are not as strict.
Relivion was FDA cleared for use in the US for migraine on 3/02/2021. It is a non-invasive, multi-channel neuromodulator system which stimulates 6 branches of the occipital and trigeminal nerves. In one study of 131 patients, 46% using the active device experienced pain freedom at 2 hours compared to only 11.8% in the sham (placebo) group. It is not yet commercially available for our office to prescribe. Hopefully it will be available soon. To learn more go to www.neurolief.com
This is now the fifth non-invasive device FDA cleared for use in the US. The other four are the Cefaly device, sTMS, GammaCore and Nerivio.
There is no data available that supports delaying any specific migraine therapy during the time of receiving the COVID-19 vaccine. We encourage all of you to continue with your current migraine treatments AND get the vaccine as soon as it is available to you. To learn more about COVID-19 resources for those with migraine go to https://americanheadachesociety.org/covid-19-resources/
Vyepti is a recently approved medication approved for the prevention of migraine in adults. It targets CGRP so works it similar to Aimovig, Ajovy and Emgality. However, it is given IV every 3 months instead of being an injectable. Key features include quick onset of action; in fact, some individuals may experience their migraine headache go away during the 30-minute infusion time frame. Vyepti requires approval by the insurance company before it can be initiated. If interested, please schedule a visit.
In any individual patient, the risk of a medication needs to be weighed against the benefits and this is especially true in pregnancy. Fortunately, most women note migraine improvement during pregnancy and can stop getting Botox. For those in whom migraines continue to be disabling, a clinical decision can be made between the provider and pregnant patient. Fortunately, a published study in 2016 looked at 232 outcomes in women receiving Botox during pregnancy. This review showed the prevalence of fetal defects (2.7%) comparable to the rate in the general population for pregnancy in the US. More recently, an additional number of cases was been reviewed bringing the total up to 397 and this shows the prevalence of fetal defects to be 2.6% once again comparable to the general population for pregnancy. In general, it is wise to avoid as much medication as possible during pregnancy. However, in some select cases, the disability of frequent migraine attacks in a pregnant woman may warrant consideration of Botox treatment to prevent migraine.
For oral Sumatriptan the maximum total daily dose is 200 mg in adults typically taken as a 100 mg tablet and then repeated 2 or more hours later. For injectable Sumatriptan the maximum total mg in adults is 12 mg and can be broken up as 3 mg, 4 mg or 6 mg spaced 1 hour apart. For generic Sumatriptan nasal spray, the maximum adult dose in 24 hours is 40 mg and taken as 1 spray 1 nostril of 20 mg and may be repeated 2 or more hours later. For the Tosymra form of Sumatriptan nasal spray the total adult dose is 30 mg taken as 1 spray of 10 mg in 1 nostril and may be repeated every hour to a maximum of 3 sprays or 30 mg. For the Onzetra breath-powered nasal delivery of Sumatriptan, the maximum total adult dose is 44 mg/4 nosepieces with the initial dose of 22 mg (2 nosepieces) followed by 2 more nosepieces (1 in each nostril) 2 or more hours later.
An oral and a non-oral form of Sumatriptan can be safely taken in a 24-hour period. Often individuals may choose to use a non-oral for a morning migraine then later in the day take an oral form of Sumatriptan. Alternatively, an individual may start with an oral tablet of Sumatriptan then choose to rescue with a non-oral route of delivery if the headache escalates.
Ubrelvy and Nurtec are 2 new oral medications approved for the acute treatment of migraine in adults. Both are in the same category of migraine medication called the “gepants.” Ubrelvy is an oral tablet 50 mg & 100 mg and is taken as needed for migraine and may be repeated in 2 hours to a maximum of 200 mg in a 24-hour period. Nurtec is a 75 mg orally dissolving tablet and is taken one tablet in a 24-hour period for migraine. Both are well-tolerated and show no evidence of medication overuse headache or vasoconstriction.
Good candidates for Ubrelvy or Nurtec include those for whom the triptans are not well-tolerated, not adequately effective, or are contraindicated. Please schedule an appointment to discuss whether Ubrelvy or Nurtec may be appropriate for you. Both have good access and affordability for those with commercial insurance.
Fioricet and other Butalbital containing medications are CYP3A4 inducers and will cause Ubrelvy to be potentially less effective. CYP3A4 is an enzyme and activation of this enzyme with an inducer like Fioricet will decrease exposure to Ubrelvy. So it would not be recommended to take both in the same 24-hour period.
Yes. In the clinical trials with Ubrelvy individuals were allowed to take a 2nd dose of Ubrelvy or take their triptan like Sumatriptan in 2 hours after dosing if not headache free. There does not appear to be any safely issue taking both Ubrelvy and a triptan in the same 24-hour period.
Both the 50 & the 100 mg doses of Ubrelvy (Ubrogepant) showed good efficacy over placebo in clinical trials. Both doses are FDA approved for the acute treatment of migraine with or without aura in adults. Either dose may be used. If you start with 50 mg and are not headache free in 2 hours, then you may consider increasing to the 100 mg as your usual dose. Importantly, we have options for dosing. Once taken, either dose may be repeated in 2 hours and the maximum in 24 hours is 200 mg. To learn more, go to www.Ubrelvy.com