orange county migraine and headache center

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.

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 is in a Toradol Injection? Can it help rescue a severe migraine?

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.

What is Nerivio? Is it available?

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.

Can I try one of the new CGRP monoclonal antibody injections if I am getting Botox every 12 weeks for my migraines? Botox helps but I would like to try one of these new CGRP injections and see if they can work together to better help with migraine prevention?

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.

Why didn’t Aimovig, Ajovy & Emgality work for me? I thought they were supposed to be the new “miracle” injections for migraine prevention. I am frustrated-please help!

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

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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

What is ergotamine? Is it better than Imitrex for acute migraine treatment?

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 am planning on getting pregnant in the next few months. What can I take for my migraine attacks once I am pregnant?

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.

Spring Newsletter: Spring Cleaning

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Spring Newsletter

Orange County Migraine & Headache Center

Spring is traditionally a time for “spring cleaning” and so it is for us at OC Migraine & Headache Center. Many of our patient handouts and resource materials date back to 2007. We have now begun the process of updating all materials on our website so that you have access to the most current information.  Here is a sneak preview: our first handout being revised is on the topic of cluster headache. New advances include the FDA approved GammaCore stimulator for acute and preventive treatment of cluster headache. It is a non-invasive vagal nerve stimulator. In addition, studies look very promising for one of the new CGRP monoclonal antibodies to get approval for cluster headache.

Very importantly, we are updating our web-based resources when you want information about a particular topic related to your headaches.  We have identified four in particular that we feel offer good information without being overly promotional. They are the following:

  1. American Migraine Foundation (the patient educational resource affiliated with The American Headache Society to which both Dr. Hutchinson & Dr. Molly belong)
    http://americanmigrainefoundation.org
  1. http://migraine.com (interactive website for migraine sufferers)
  2. http://migraineagain.com (trusted healthcare advice from providers around the world)
  3. National Headache Foundation (large membership base for all types of headache)
    www.headaches.org

 

As we update and work to improve our website (www.ocmigraine.org) we welcome your feedback both positive and negative. Please address your feedback and/or suggestions for new material on our website to our office email at info@ocmigraine.og

Thank you for your trust in our headache-focused medical practice. This is truly an exciting time for headache with many new and emerging treatments both for acute and preventive. We look forward to your next appointment so we can determine which new treatments may be best for you.

Enjoy your spring-cleaning,

Dr. Susan Hutchinson & Dr. Molly Rossknecht

I am trying to get off narcotics. What are some non-narcotic treatment options to rescue me when I have a severe migraine?

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.

What is the difference between Aimovig, Ajovy, and Emgality for migraine prevention?

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.

I have cluster headaches. Would any of the new CGRP monoclonal antibodies (CGRP mABs) work for cluster headache prevention?

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.

Winter Newsletter: Major policy changes regarding Opioid and Narcotic prescribing at OCM&HC

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Winter Newsletter: Major policy changes regarding Opioid and Narcotic prescribing at OCM&HC

We hope all of you are having a wonderful start to your Holiday Season. This has been a very exciting year for migraine sufferers with the launch of three Calcitonin gene-related peptide (CGRP) antibodies for migraine prevention. Aimovig was released in May. Both Ajovy and Emgality were released in September. This is the first category of migraine prevention that was developed specifically for migraine. Many of our patients are already seeing significant improvement with a reduction in both migraine frequency and severity.

For acute migraine treatment, there are oral CGRP antagonists in development. In addition, non-invasive neurostimulators are available for acute and prevention treatment of migraine and cluster. They include the Cefaly device, the SpringTMS (transcranial magnetic stimulation), and the GammaCore (non-invasive vagal nerve stimulator).

With so many specific migraine treatments emerging, our office has revisited the issue of narcotic and opioid prescribing for migraine. Narcotics like hydrocodone are not FDA approved for acute or preventive treatment of migraine or cluster headache. In addition, they can lead to medication overuse headache which can cause other treatments to not work as well. Lastly, they can cause drowsiness, depression, and can cause death in the case of an overdose.

The state of California is strictly monitoring the prescribing of narcotics and opioids. Responsible prescribing includes random urine drug screening, contracts, and limits on how many pills can be prescribed at one time. We have decided there are too many current restrictions and future restrictions for our office to prescribe any amount of narcotics. We are not pain specialists nor do we wish to be. Therefore, as of January 2019, we will be a “narcotics free” office. No exceptions will be made. All of you currently receiving a narcotic prescription from our office will receive a letter as well as a list of pain specialty practices in the local area. We will help with your transition to a pain specialist for future narcotic prescriptions. For those of you only needing a small amount of a narcotic to rescue a severe migraine, you may be able to request from your primary care provider (PCP).

There is an abundance of non-narcotic ways to treat a severe migraine attack including a Toradol injection, occipital nerve blocks, standing orders at the Hoag Infusion Center for IV medications and IV fluids, sphenopalatine ganglion blocks (SPG’s) administered in our office, a course of steroids, and anti-nausea injections or suppositories. In addition, the new CGRP monoclonal antibodies have helped some of our patients to not need a narcotic as their migraines are so much better.

We encourage you to make an appointment to come in and review your migraine plan. This is an exciting time for migraine sufferers with all the new treatments available. Let’s work together to help you be as headache-free as possible in 2019.

Happy Holiday Season,

Dr. Susan Hutchinson and Dr. Molly Rossknecht
Staff

Fall 2018 Newsletter

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Dear Patient,

We are pleased to announce that a second CGRP Monoclonal Antibody, Ajovy, was approved by the FDA on 9/14/18 for the prevention of migraine in adults. Like Aimovig, it is a subcutaneous injection. Both are well-tolerated and have been shown to be highly effective in clinical trials.

Ajovy is available as a pre-filled syringe vs the auto-injector with Aimovig. Ajovy offers the option of a quarterly (every 3 months) dosing. However, it requires 3 injections for the quarterly dosing. A monthly single subcutaneous injection is also available. For some patients, the quarterly dosing could be done as part of an office visit every 3 months and may be more convenient than the monthly self-injection.

Is one better than the other? The short answer is that we don’t know. There have not been any comparison trials. All trials with this new category of migraine prevention with CGRP monoclonal antibodies were conducted with the active drug vs placebo.

 

Who is a candidate for a CGRP monoclonal antibody (CGRP mAB)?

Any adult migraine sufferer who has 4 or more disabling monthly migraine days would be a candidate. Most insurance companies will require a failure or intolerance to at least 2 standard oral migraine preventives. Currently, this new category for migraine prevention is only approved for adults 18 and over in the US. There is not enough data to know if this new category is safe for pregnancy and lactation.
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We encourage you to make an appointment to explore this new preventive option for migraine. We may be able to give you the 1st injection in the office as part of your visit.

We are entering a new era of headache medicine with the advent of migraine specific preventive treatment that is effective and well-tolerated. You deserve to live a life as free of migraine as possible. We are here to help.

For more information, go to www.Aimovig.com and www.Ajovy.com

 

Dr.  Susan Hutchinson, Dr. Molly Rossknecht, & Staff

Orange County Migraine & Headache Center

9/24/18

Aimovig (CGRP Monoclonal Antibody) Update

Good news: Amgen/Novartis is offering 2 months of injectable Aimovig to all who qualify (adults with commercial insurance) once a service request form is completed by both the patient and the prescriber office.

To access the patient form that needs to be completed, go here: https://www.aimovighcp.com/-/media/project/aimovighcp/files/service_request_form.ashx

Once this opens, click on the service request form. Complete the top half in full including all your demographics and your insurance information. The insurance information must be filled in-we have been told it is not sufficient to simply fax in a copy of the insurance card. Also you need to sign and date. Electronic signatures are not accepted.

Once completed and signed you can fax to us at 949-861-8719 or send as an attachment to our email info@ocmigraine.org

You will need to call and make arrangement to pay $25.00 as a processing fee to cover our time in completing our part of this form and faxing in and following up when additional information requested.

We recommend an office visit approximately 1 week after your 2nd injection to document efficacy and to help with insurance approval. As long as our office is documenting that we are trying to get insurance, Amgen/Novartis will continue to provide the monthly 70 mg injection at a small copay fee. We are very pleased with the strong commitment that Amgen/Novartis has made to make available this preventive treatment to almost everyone for 1 full year.

You are strongly encouraged to go to www.aimovig.com to learn more about this first CGRP Monoclonal Antibody that has now come to market for the prevention of episodic and chronic migraine.

In good health,

Drs. Susan Hutchinson & Molly Rossknecht
Orange County Migraine & Headache Center
May 28,