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.

Summer Newsletter 2020

(Download PDF)

Summer Newsletter 2020

Orange County Migraine & Headache Center

Today is July 4th, a day we celebrate our country and our freedom. Due to COVID-19, this is a July 4th unlike any we have ever had in our country. The good news is that we will eventually have a vaccine and life can return to somewhat of a new “normal”.

Today can also be a time to celebrate freedom from migraine. Migraine still can not be “cured” but can be much more manageable due to new treatments for both acute & prevention of migraine attacks. These new treatments are target specific for what is happening during migraine and are better tolerated & more effective than prior treatments. New preventive treatments include the injectable CGRP monoclonal antibodies: Aimovig, Ajovy, and Emgality. Recently, the first CGRP monoclonal antibody for IV infusion every 3 months got approved; it is called Vyepti. Many of our patients feel as if they have their life back with this new category for prevention.

In addition, there are new medications for the acute treatment of migraine with or without aura and these include Ubrelvy, Nurtec, and Reyvow. All are target specific and good options if the triptan category (Sumatriptan, Rizatriptan, etc.) are not well-tolerated, not effective enough, or for those for whom the triptans are contraindicated due to coronary artery disease or peripheral vascular disease. Unlike the triptans, the new oral medications do not cause vasoconstriction and do not show any evidence of medication overuse headache.

Also, the newest device to come to the market for migraine is called Nerivio and is helping many patients with their migraine attacks. It is a non-invasive pain modulator worn on the upper arm for 45 minutes for a migraine attack. To learn more, watch this short video:

https://www.youtube.com/watch?v=tkO2A_g7q4Qhttps://www.youtube.com/watch?v=tkO2A_g7q4Q

We also want to point out four non-pharmacologic approaches that have helped us personally as well as many of our patients. They include exercise, physical therapy, Pilates/yoga, and meditation/biofeedback/stress-reduction. Exercise in any form can be therapeutic. Dr. Hutchinson loves the out-of-doors so when her gym reopened and offered an Outdoor Cross-Fit Class, she signed up and loves it! In addition, she runs 3-4 miles every other day. Dr. Molly has a Peloton bike and loves the flexibility & convenience of working out from home. Pick what works for you….the important point is to pick and start an exercise routine. Your body including your migraines will thank you!

Posture can affect headache as well as neck pain. If you are suffering from neck pain, consider a physical therapy evaluation with Dr. Pete Rumford in Irvine. He is affiliated with IPA Physio and has helped both Dr. Hutchinson & Dr. Molly with 1:1 sessions. To learn more, go to https://ipa.physio/oc/

For Pilates, consider on-line classes such as offered by Streaming-Salt Pilates, at www.takemetosalt.com.

Lastly, for those wanting to learn more about the role of biofeedback & meditation in helping headache go to www.dawnbuse.com  Dawn Buse is a psychologist who has done extensive research in the field of migraine as it related to biofeedback & mediation. Her website offers lots of helpful information and tools to do treatments like biofeedback on your own. Dr. Buse is a good friend of ours and we highly recommend her website.

In closing, we hope all of you stay healthy and as headache free as possible. We are here to help!

In good health,

Dr. Susan Hutchinson & Dr. Molly Rossknecht

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.

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

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.