My Botox wears off after 10 weeks but my insurance will only let me come in every 12 weeks. What can I do during the 2 weeks that it is wearing off?

Orange County Migraine & Headache Center

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.

 

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

What is Elyxyb?

Orange County Migraine & Headache Center

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.

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

Can you tell me more about a new form of DHE that will be delivered nasally? I have used before as an injectable. It was quite helpful and the nasal delivery sounds easier.

Orange County Migraine & Headache Center

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/

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

When should I stop using my Emgality injection if I want to get pregnant?

Orange County Migraine & Headache Center

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.

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

What is the difference between FDA cleared vs. FDA approved?

Orange County Migraine & Headache CenterFDA 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.

 

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

I heard a new device was just approved for migraine in the US. Can you tell me more about it?

Orange County Migraine & Headache CenterRelivion 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.

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

Should I delay getting Botox or injecting with my CGRP mAB (Aimovig, Ajovy, or Emgalit) before or after receiving the COVID-19 vaccine?

Orange County Migraine & Headache CenterThere 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/

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

What is Vyepti?

Orange County Migraine & Headache CenterVyepti 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.

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

Is Botox safe during pregnancy?

Orange County Migraine & Headache Center

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.

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

How much Sumatriptan can I take in a 24 hour period?

Orange County Migraine & Headache Center

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.

 

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

What is the difference between Ubrelvy and Nurtec?

Orange County Migraine & Headache Center

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.

 

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

May I take Fioricet after taking Ubrelvy for acute migraine?

Orange County Migraine & Headache CenterFioricet 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.

 

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

May I take my Imitrex (Sumatriptan) in addition to Ubrelvy in the same 24-hour period?

Orange County Migraine & Headache CenterYes. 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.

 

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

Should I take the 50 or the 100 mg dose of Ubrelvy, the new migraine medication?

Orange County Migraine & Headache Center

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

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

What are some good websites for learning about new treatments for migraine that are not overly promotional?

Orange County Migraine & Headache CenterOur office recommends the following websites as good resources to learn more about new treatments for migraine:

Our practice website www.ocmigraine.org is also a good source for learning about new migraine treatments and we try to update regularly.

 

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

I heard that a new migraine medication called Reyvow has been approved. What is it?

Reyvow is a new migraine medication FDA approved for acute migraine treatment. Another name for it is Lasmiditan. Although FDA approved, it cannot be prescribed until the DEA decides what category to put it in as it can cause dizziness and sedation. There will be some sort of warning on not driving for a certain number of hours after taking. Despite the sedation & dizziness as possible side-effects, it does not cause any vasoconstriction like the triptans and may be useful for patients who cannot take the triptans due to cardiac issues and for those for whom the triptans are ineffective or poorly tolerated. We expect Reyvow to be available by February 2020.

 

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

What is Ubrogepant? I heard it would be available soon.

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.

 

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

What’s New For Migraine Prevention?

A new category of medication for prevention of migraine is in the late stages of clinical trials and is expected to be available by early 2018. This category is called CGRP Monoclonal Antibodies. It will be administered either as a monthly self-administered injection or by IV (intravenous) every 3 months. Four pharmaceutical companies (Alder, Amgen, Lilly and Teva) are all developing CGRP drugs and are competing to be the first to come to market.

The headache community is very excited about this new category of preventive treatment as it is working quite well in clinical trials. This can be a great option for Botox non-responders or others not doing well with their current treatment.

Stay tuned!