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.
To make an appointment, please call 949-861-8717.
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.
To make an appointment, please call 949-861-8717.
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.
Our 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.
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.
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.
Fall Newsletter 2019
Orange County Migraine & Headache Center
“New Beginnings”
Why the title of “New Beginnings” for this newsletter? Several reasons are behind this title. First, Dr. Hutchinson became a grandmother on Sunday, November 17th when her daughter brought Evelyn Rose into this world. Secondly, this is truly a time of “new beginnings” for many of you with migraine and cluster headache. New advances for prevention of migraine including the anti-CGRP monoclonal antibodies (Aimovig, Ajovy, and Emgality) have brought improved quality of life to many of you. These medications are a positive step for those who have previously failed or been intolerant of non-specific preventives including the anti-depressants, anti-hypertensives, and anti-epileptics. In addition, Emgality has received the approval for prevention of episodic cluster, which although far less common than migraine, is so disabling is often referred to as the “suicide” headache.
Look for new treatments coming to market for the acute treatment of migraine. These include the Nerivio device (discussed in the last newsletter), Tosymra (the new nasal mist of Sumatriptan), and new oral medications including Reyvow and oral gepants. These new acute migraine treatments will be especially good for those of you who have not found triptans effective, have poorly tolerated them or cannot take due to contraindications such as cardiac or vascular disease. The triptans cause some vasoconstriction after taking whereas the new Reyvow and the emerging oral gepants do not cause vasoconstriction. We encourage you to set up an appointment in early 2020 to review your current acute and preventive treatment plan so we can help you live your life as free of migraine & cluster headache as possible.
As the new year approaches it is a great time to evaluate and fine-tune our practice. Here are a few practice changes and some reminders regarding office procedures and policies!
We first want to make all our patients aware that our procedure fees for Nerve Blocks and Injections have been reviewed and pricing adjustments have been implemented. This may impact a small percentage of you so please ask about the cost of your procedure at the time of scheduling. We want to avoid any surprises when you check-out. For specifics, please call our office.
Secondly – We want to remind everyone about the proper use of the after-hours phone calling and email messaging.
We are available after hours for urgent issues that you feel cannot wait until we are back in the office. The after-hours # is 949-514-4429. Note that this line is for voice messages only. Please do not text any requests to this number. Text messages will not be read and will be deleted. In addition, do not call the after-hours line for refills. Refills are only handled during regular office hours and can take up to 3 business days to respond to.
Emails sent to our office at info@ocmigraine.org are screened and forwarded to the appropriate physician. Emails take up to 5 business days to respond to. If you have an urgent issue, please call the office instead of sending an email. Dr. Hutchinson and Dr. Molly need to prioritize taking care of patients on their schedule that day and may not have time to read emails as timely as you may want. Please understand, as you will also be given the priority when you come in for a visit.
The Holiday Season has arrived. Please enjoy time with your loved ones.
Happy Holidays to all,
Dr. Susan Hutchinson
Dr. Molly Rossknecht
Aurora, Bailey, and Norma
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.
To make an appointment, please call 949-861-8717.
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
To make an appointment, please call 949-861-8717.
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.
To make an appointment, please call 949-861-8717.
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.
To make an appointment, please call 949-861-8717.
Summer Newsletter 2019
Orange County Migraine & Headache Center
Summer-a time to take vacation, enjoy longer days of sunshine, and a time to learn about some newly approved migraine & cluster headache treatments. This is truly an exciting time in the headache world. In recent weeks, three new treatments have received FDA approval in the United States. Emgality, one of the 3 CGRP monoclonal antibodies approved for prevention of migraine, got approved for the prevention of episodic cluster. Dr. Hutchinson will be going to Indianapolis (home of Lilly pharmaceutical) in July to learn the specifics of how to prescribe for cluster headache and will be a trained speaker to educate other health care providers. Cluster headache patients will be able to inject Emgality just during their cluster periods unlike migraine patients who inject every month for prevention. So, if you or someone you know has episodic cluster headaches, plan a visit at the end of July or sometime in August to get this treatment and have it on hand before your next cluster headache flare-up.
Two new treatments have received approval for migraine headache. One is called Tosymra and is a novel nasal delivery of Sumatriptan. It contains a patented membrane permeater enhancer that allows quick absorption into the nasal tissue. In fact, it has been shown to act as quickly as Sumatriptan 4 mg injectable. No needle and better tolerated than the injectable-a great option for migraine attacks associated with nausea and/or vomiting or for those attacks that have rapidly progressed and for which an oral tablet may not work quick enough to bring relief. The other recently approved product is a device called Nerivio Migraine. It is a remote electrical modulation device placed on the arm and controlled by your smartphone. It is for the acute treatment of migraine. Some advantages include good tolerability and non-invasiveness. To learn more, go to www.Theranica.com. Dr. Hutchinson will be attending an Advisory Board on July 13th in Philadelphia to learn more about this new device.
Lastly, I want to being to your attention that we offer both B-12 and B-complex injections in our office. They can address B-vitamin deficiencies as well as help energy. They can be especially helpful if you are stressed, recovering from an illness or surgery, suffer from fibromyalgia or chronic fatigue syndrome, or have absorption issues due to gastric by-pass. If you are interested in either injection, they can be scheduled as an injection visit with Aurora, our certified medical assistant (CMA).
If you are looking for updated information in the resource/handout section of our website, the following 4 handouts have been recently updated: Preventive Treatment of Migraine; Acute Treatment of Migraine; Medication Overuse Headache; and Cluster Headache. We are going to work on updating all handouts on our website. Feel free to offer suggestions you may have to improve our website and educational services to you, our patient.
Have a wonderful summer. We look forward to seeing you in our office so that we can help you be as headache-free as possible this summer.
Warm regards,
Dr. Susan Hutchinson & Dr. Molly Rossknecht
June 21, 2019
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.
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.
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.
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.
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.
To make an appointment, please call 949-861-8717.
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.
To make an appointment, please call 949-861-8717.