Dr. Susan Hutchinson has contributed to the continuing education webcast “Migraine Management for the Nurse Practitioner: Acute and Preventive Therapies to Reduce Burden of Disease”. The intended audience for this activity is nurse practitioners and other health care professionals involved in the management of patients with migraines. You can learn more by visiting https://www.mycme.com/courses/migraine-management-for-the-nurse-practitioner-8009
Miles for Migraine Event San Diego
Saturday November 6th
Join us for the 3rd Annual Miles for Migraine San Diego Event. Due to COVID, this event has been changed to virtual so we won’t be running along beautiful Mission Bay as we did in 2019. However, our practice has still formed a Team and we plan to join together on Saturday, November 6th, for a walk at Crystal Cove followed by breakfast at the Beachcomber.
Our team is called OC Migraine. Feel to join our team and participate with us in person or virtually by doing an activity on your own that day. All funds raised will be used to raise awareness of migraine and to advance migraine research. To learn more about Miles for Migraine, visit www.milesformigraine.org
Donations are welcome and any size donation is appreciated. The link to donate is
https://sd.milesformigraine.org/pledge/team/335299
In coming weeks, we will be asking for donations in lieu of fees normally charged to complete forms and write letters.
For any questions, feel free to email us at info@ocmigraine.org
Thank you!
Orange County Migraine & Headache Center
You can also download and print this info here (PDF)
Dear Patient,
Happy New Year 2021! Many of us were glad to say good-bye to 2020 but admittedly, 2021 has had its challenges with ongoing COVID-19 cases, vaccination glitches, political unrest, and financial stress. Our practice is committed to being there for you during this time.
All of us have now been vaccinated and continue to take special precautions in sanitizing our office and limiting the number of you that come in at any one time. Many of you have appreciated the convenience of virtual phone visits for follow-up and we will continue to offer that option for existing patients.
We are very excited to announce the addition of two new staffmembers to Orange County Migraine & Headache Center. Jamie Kolak is our new front office receptionist and works from 8:15 am-1 pm Monday-Thursdays. She brings 14 years of medical front office experience with her and has great communication skills. Aurora continues to work full-time as our certified medical assistant (CMA) and will now be able to devote more time to back office responsibilities, Botox approvals, and prescription refills. Bailey, our other receptionist, is completing her dental hygiene training and has had to reduce her hours; however, she still devotes time to non-Botox prior authorizations and billing. We are proud of all three of them. They make a great team.
Our other new addition is Allison Kennedy, a Physician Assistant (PA), who is available to see headache patients on Wednesday afternoons. She has over 5 years of experience seeing headache patients and is skilled with Botox injections for migraine patients, nerve blocks, and evaluation of headache. We anticipate her hours to increase over time.
Dr. Hutchinson and Dr. Molly Rossknecht continue to provide care for headache and mood disorders. We continue to strive to provide compassionate and state-of-the-art treatment for headache and mood disorders. A patient survey will be offered in the near future providing valuable feedback on how we are doing and what we can do better. Your feedback is greatly appreciated.
And behind the scenes is our hard-working office and business manager, Norma Colgan. She continues to be our “silent hero.” Our practice could not run without her.
We look forward to continuing to service you, our patient, in 2021, and welcome your feedback. May 2021 be a year of renewal and healing for us as individuals, for our country, and for our world.
Drs. Susan Hutchinson, Molly Rossknecht & staff
On Saturday, November 9th, 2019, Orange Country Migraine & Headache Center participated in the Miles for Migraine Walk and Run in San Diego, CA. Sixteen OCM staff members and patients participated! Additionally, Orange County Migraine & Headache Center took home the prize for raising the most donations of any team. Over $3,000!
Thank you to everyone who participated and/or donated for this very worthy cause, in which proceeds go to migraine and headache research.
OCM Migraine Team (to the left)
Dr. Susan Hutchinson
The Racers
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.
CGRP stands for Calcitonin Gene-Related Peptide. It is a neuropeptide located in neurons (nerve cells) and smooth muscle throughout the part of the nervous system that is part of the migraine process. When a migraine trigger occurs in a susceptible individual, CGRP levels increase and this increase is felt to be major part of the pathophysiology of migraine. Research has demonstrated elevated CGRP during migraine attacks. In addition, research has demonstrated relief of a migraine attack when a CGRP blocking medication is given. This blocking of CGRP is the mechanism of action of the new category of CGRP Monoclonal Antibodies that are now coming to market for the prevention of migraine. The first one available, Aimovig, blocks CGRP activity at the receptor site. To learn more, go to www.Aimovig.com and www.scienceofmigraine.com
To find out if this new preventive treatment makes sense for you, please schedule a visit at our office. We are very excited about this new treatment.
To make an appointment, please call 949-861-8717.
The new category of CGRP Monoclonal Antibodies for migraine prevention is ideally suited for anyone suffering from migraine at least 4 days per month. The first one is now available and is called Aimovig. It is approved for adults 18 and over. It is not recommended in women who are breast-feeding or pregnant. Most likely insurance companies will require failure or intolerance of at least 2 standard oral migraine preventives. The best next step would be to come in for an appointment so we can determine if Aimovig would be a good next step for you.
To make an appointment, please call 949-861-8717.
Increasing evidence from research shows that narcotics can worsen a headache condition by causing narcotic/opioid hypersensitivity. This means that over a period of time no acute medication will work as well. Narcotics are not migraine specific and are not FDA approved for the treatment of migraine. There are migraine-specific medications, oral and non-oral, that are much more appropriate for the treatment of an acute migraine attack such as the triptan category.
To make an appointment, please call 949-861-8717.
There can be many reasons for worsening of a headache pattern during winter months. Weather changes can be a factor, especially drops in barometric pressure that can occur before a storm. Turning heaters on can be a trigger if dust or mold has accumulated in the air ducts. For some, Holiday stress can be a trigger either from travel or entertaining. Also, there is a tendency to fall off your exercise program, not eat as healthy, and not have a consistent sleep schedule during the Holidays. Now that the Holidays are over, resuming a healthy life style should help.
To make an appointment, please call 949-861-8717.
Dear Patient,
The beginning of the year allows a “fresh start” including setting goals and for some, a new direction to take in life. For our practice, the new direction for 2018 is to move towards being a narcotic/opioid free practice by the end of 2018. Heightened scrutiny and increasing regulation for prescribing narcotics like hydrocodone has occurred in this county. Some pharmacies now set limits on how many days a narcotic may be dispensed. As prescribers, we are required to regularly monitor controlled medication use on a statewide system called CURES.
Our medical practice is devoted to helping those with headaches and mood disorders. We are not a pain practice and are not set up to do urine drug testing as pain practices commonly do as part of monitoring their patient’s narcotic use. In addition, narcotics can work against good headache control by promoting medication overuse headache. Narcotics can create a condition called opioid hypersensitivity in which medications do not work as well. This is possible even with non-narcotic treatments such as triptans.
We realize this change in our practice will cause some of you to have to begin seeing a pain specialist if you are unable or unwilling to give up your narcotic. Our office will help in this process by referring you to a pain group that will work with you to take over the prescribing of the narcotic. We are actively meeting with pain groups to create a network of providers willing to see our patients.
During this process, we will continue to refill your narcotic as we don’t want our patients to suffer withdrawal symptoms. However, any narcotic/opioid medication will only be filled as part of an office visit and cannot be requested to be mailed or picked up in our office. For most, that will mean a monthly visit and the amount prescribed must last 1 full month. Early refills will not be honored. Activity will be monitored monthly on the CURES data base.
Fortunately, there are many effective non-narcotic treatment options for migraine and other headache disorders. Getting off your narcotic may be one of your goals for 2018 – We can help.
In closing, this change in our practice is not meant to be a punishment for those of you taking narcotics. We are moving our practice in a healthier direction and hope you come with us in this journey.
Respectfully,
Susan Hutchinson MD Molly Rossknecht, DO
Orange County Migraine & Headache Center
Yes, they are not uncommon. Typical symptoms include visual symptoms (flashing lights, zig-zag lines, or the absence of vision in all or part of the visual field). Other symptoms can include tingling on one side of the body and/or slurred speech, or vertigo. These types of migraines are often referred to as aura without headache (acephalgic migraine). Symptoms may last from minutes to days. Treatment varies but may include migraine specific medication. These symptoms should always be evaluated by a healthcare provider for a correct diagnosis.
To make an appointment, please call 949-861-8717.
Hello Everyone,
I hope this finds you enjoying your summer. In this newsletter, I would like to share with you a new treatment we now offer for migraine and cluster headache. In addition, I will review & update current treatment options.
Sphenopalatine Ganglion Block
The SPG is the largest group of neurons (nerve cells) outside the brain and can be reached via the nose. In the past, Q-tips were used and after being soaked with a numbing (anesthetic) medication were inserted far back into the nose to try to reach the SPG. However, this process caused nasal discomfort and was not precise in getting to the SPG. As a result, SPG blocks did not become common in a headache practice.
Dr. Tian Xia, a pain specialist and anesthesiologist, has invented the Tx360. It is a patented device that inserts into each nostril and contains a small, flexible, soft plastic tube that is advanced into the nose and is able to reach the SPG. It delivers a precise amount of anesthetic medication (Bupivacaine .3 cc) to each SPG. It is overall well tolerated and can be performed in 5 minutes in the office setting. By blocking the SPG, the migraine path can be blocked and the patient can get relief from their migraine. To see an animation of the SPG procedure, go to www.tianmedical.com.
It would not be necessary for anyone to drive you to the office. You can drive yourself after the procedure, as it is non-narcotic and non-sedating. This procedure can help to treat a bad headache and can also be done as a preventive treatment. For best results for prevention, it would be necessary to come in 2 times per week for 3-6 weeks.
Eye-Brain Update: For a limited amount of time, the Eye Brain Medical Center has agreed to treat our patients at no charge. Candidates include patients having daily lowgrade headache that worsens as the day progresses and is aggravated by prolonged reading or working on the computer. In addition, dry eyes and sensitivity to light are common symptoms that cause what has been termed “Eye-Graine”. This type of headache is not the same as migraine; the cause is felt to be from the eyes not working well together. If a patient is screened and felt to be a candidate for treatment at the Eye Brain Medical Center (located in Orange, CA), then they are fitted with NeuroLenses (glasses with prisms in them to help the eyes work better together). For more information, go to www.eyebrainmedical.com
CGRP Clinical Trial Available: CGRP Monoclonal Antibodies for migraine prevention appear to be very promising and were discussed in the last newsletter. This treatment is only available through clinical trials until FDA approved. If interested, call the following research coordinators: Mark Gonzalez 714-774-7777 (Anaheim) or Shelly Asbill 562-304-1759(Long Beach)
Cefaly Headband: This FDA-approved device for migraine is working well for many of our patients. We now offer a free 20 minute demo if interested. In addition, we have 3 units available to rent. For more information, see the description in our last newsletter and visit www.Cefaly.us
Treximet: This acute migraine medication is a combination of Sumatriptan and Naprosyn and works better than either medication by itself. Through a special program with Newport Lido Pharmacy, it is now available to most of our patients for $20 or less for 9 tablets. Newport Lido will ship to you at no charge.
Sumavel Dose Pro: Sumatriptan 6 mg injectable needle-free is now available through Newport Lido as well for a reasonable cost for most patients. This needle-free injection is a great way to rescue a severe migraine or cluster headache. Trokendi XR: This name brand Topamax does not cause the mental sluggishness/word retrieval problems that generic Topamax causes. It was discussed in the last newsletter. It is now available through Newport Lido for as low as zero co-pay for many patients.
Wherever your summer travels take you, I wish you a very pleasant rest of your summer. I look forward to seeing you to review your current headache management plan!
Sincerely,
Susan Hutchinson, MD Director-Orange County Migraine & Headache Center
Three New Treatments for Chronic Migraine
Dear Patients,
The official day of summer is rapidly approaching. Longer hours of daylight, days at the beach, outdoor BBQ’s, vacations, and a break from the more structured September-May time frame is welcomed by many. But for the migraine patient, the heat of the summer months can be a frequent cause of headache exacerbation. Staying well-hydrated and avoiding being out in the middle of the day are common-sense precautions. Are there some other treatments that may prove helpful for those who dread the summer months and feel “nothing is working” for them?
In this newsletter, I would like to discuss three novel treatment approaches to consider for those frustrated with their current migraine pattern.
- The Cefaly Headband: this is the first medical device approved by the FDA for the prevention of migraine headaches. It is a small, portable battery-powered headband that is worn across the forehead and fits over the ears on both sides. This device applies an electric current to the skin in the center of the forehead just above the eyes. This current is similar to that of other transcutaneous electrical nerve stimulators (TENS) that have been used for years in the treatment of pain and are frequently part of physical therapy. The electrical current of the Cefaly device stimulates branches of the trigeminal nerve, which is associated with migraine headaches. There are 3 settings for the device: one for prevention of migraine; one for acute treatment of migraine; and one for relaxation. In the patient satisfaction study of 2,313 Cefaly users in France and Belgium, more than 53% of patients were satisfied with Cefaly treatment and were willing to buy the device for continued use. The device is approximately $350 and requires a prescription to purchase. So far, in my practice, about ½ of patients who have tried the device are satisfied and happy with the results so this is consistent with the findings in the patient satisfaction study.
- Myers Cocktail IV Treatment: this is an IV treatment containing calcium gluconate, magnesium, B-vitamins, Vitamin C, and msc. Other amino acids/electrolytes administered in an IV bag of 100 cc solution. It takes about 6 minutes to go in. It is not covered by insurance and costs just under $100 for the basic IV treatment. According to a physician colleague of mine, it is recommended as a monthly treatment for maintenance. It is available at Link Medical in Newport through Dr. Garrett Wdowin who is a Naturopath MD (NMD). The phone number to schedule an appointment and/or IV treatment is 949-465-0770. My opinion is that this IV treatment may benefit some migraine patients who are frustrated with their current treatment and this treatment appears to be quite safe.
- California eyeBrain Medical Trial: For some chronic daily headache patients, there may be an imbalance between the patient’s peripheral vision and central vision. This could cause overstimulation of the Trigeminal nerve and be contributing to chronic daily headache and neck pain. For patients who have chronic daily headache (headache 15 or more days a month for over 3 months) and have dry eyes, sensitivity to light, stiffness in shoulders or neck, and/or lethargy (fatigue), then you may be a candidate for a novel treatment for your headaches. There is a clinical trial to evaluate a new treatment to address imbalance between peripheral and central vision; there is no charge to be in this trial. To see if you are a candidate for this eyeBrain free clinical trial, go to http://eyebrainmedical.com/self-evaluation website and take the self evaluation of 12 questions. This should only take about 3 minutes to complete. You will then be contacted in 24 hours to determine your eligibility for this study. The treatment involves a progression or prisms in glasses to address the imbalance contributing to the frequent headaches. The study dates in Orange County are June 23-26th. I have met with the study coordinators and was pleased with their honesty and genuine interest in helping chronic daily headache patients with their approach. Their study appears to be quite safe and non-invasive; I like the fact that patients are screened ahead of time by the on-line self-evaluation. This helps to minimize wasting anyone’s time if they are not a candidate for this study. My advice: check it out and take the on-line self-evaluation; you have nothing to lose.
In summary, I have discussed three novel treatments for migraine patients. If you feel you are a candidate for any of these treatments, please call our office and set up an appointment to discuss them further. For the Cefaly headband, a prescription is required to order the device. This could be a great time to come in and have your migraine treatment plan evaluated and improved. I look forward to seeing you in my office in the near future and in the meantime, have a wonderful summer.
Sincerely,
Susan Hutchinson, MD Director-Orange County Migraine & Headache Center
Dear Patients,
Happy New Year to Everyone. I hope 2014 is off to a good start for you and your family. On a personal note, I got married this past November and start off 2014 as a happily married woman! Personal goals including adding Pilates and Yoga to my exercise regimen.
Professional goals for my practice for 2014 include providing you with the very best medical care I can for headaches and mood issues. In order to provide you with quality care, I have decided to not sign any insurance contracts. My practice will continue to be fee-for-service. We will, however, continue to bill your insurance as a courtesy.
For existing patients, we now offer Saturday hours and phone visits. We also have “emergency” slots to better accommodate patients who need timely care.
I want my practice to be “predictably consistent” for patients so certain practice policies will be strictly enforced in 2014. These policies include:
Late Policy
There is a 10 minute grace period. If you anticipate arriving more than 10 minutes late, please call first to see if we can accommodate you. In some cases, we may need to reschedule your appointment.
Prescription Requests
Allow 3 business days for prescription refills. Ask the pharmacy to fax the request to us. In most cases, we will handle the refill electronically. It is very important we have your preferred and correct pharmacy phone number and fax number in our system.
Prior Authorization Requests
Allow 2 weeks for processing all prior authorization requests. Options while waiting include switching to the generic alternative covered by your insurance or paying out of pocket for a 2 week supply. Note: If the prior authorization is for Botox, it can take up to 6 weeks.
Botox
Dr. Hutchinson is a certified Botox injector for chronic migraine. The response rate is 85-90% in our practice. Make an appointment to see if Botox right for you. Visit our websitewww.ocmigraine.org for additional information about Botox for chronic migraine.
New Procedures
New nerve block type procedures and non-invasive stimulators may be treatment options in the future for frequent headache sufferers. Dr. Hutchinson is researching which new procedure options would be the best to start incorporating into her practice.
Emails
Allow 5 business days for response to emails. Remember that email is NOT for prescription issues or to make an appointment or for urgent issues. Email is for non-urgent follow-up questions or for providing a progress report to Dr. Hutchinson.
Urgent Issues
Call our office 949-861-8717 for urgent needs. My staff will help you with making an appointment, coordinating refills, and asking Dr. Hutchinson how to handle your need if of a serious nature. Electronic messages may be put in for Dr. Hutchinson to review and handle as she has time in her schedule.
I look forward to working with you to live a life as free of headache and mood issues as possible. See you soon for your next visit.
Hoping for an excellent 2014 for you,
Sincerely,
Susan Hutchinson, MD Director-Orange County Migraine & Headache Center
In the course of treating both migraine & depression, my patient population of fibromyalgia has grown. Fibromyalgia often co-exists with migraine and depression. If an individual has migraine headaches, that person is more likely to also have fibromyalgia than the general population. The same is true for depression. This newsletter is devoted to this disabling condition.
Fibromyalgia is a common and very disabling condition that affects 5% of women and 1.6% of men in the general population. It is considered an idiopathic disorder of chronic generalized musculoskeletal pain. The pain is in all 4 body quadrants (i.e. the whole body) as well as in specific soft-tissue tender points often called “trigger points”. A patient with fibromyalgia will be very sensitive when light pressure is applied to these trigger points, often located in the neck and upper back. Other symptoms may include fatigue, sleep disturbance, stiffness, and decreased concentration. I have also been told by some of my patients that they feel “flu like” symptoms, tingling or burning sensations or at times, achy all over.
What causes fibromyalgia? The exact cause is unknown but it appears to be from altered pain processing, creating an increased sensitivity to light touch that normally should not be painful. Similarly, migraine patients have an increased sensitivity to their environment, e.g. to changes in barometric pressure or the drop in estrogen with menses. There are striking similarities between migraine & fibromyalgia.
Treatment includes both pharmacologic and non-pharmacologic options. There are 3 FDA-approved medications for fibromyalgia. They are:
- Lyrica (pregabalin)
- Cymbalta
- Savella
Other medications commonly used for fibromyalgia but not FDA-approved include the following:
- Tricyclic Antidepressants such as Elavil and Pamelor. This class of medication has been found helpful in fibromyalgia but side-effects include sedation, dry mouth, constipation and weight gain.
- Selective Serotonin Reuptake Inhibitors (SSRIs) such as Prozac, Zoloft & Lexapro. This class of medication has shown mixed results in helping fibromyalgia and would not be considered first-line therapy.
- Selective Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) such as Effexor and Pristiq. This class of medication has shown greater effectiveness than SSRIs and includes 2 of the FDA approved drugs for fibromyalgia: Cymbalta & Savella.
- Anti-epileptic Drugs (AEDs) such as Neurontin (gabapentin), Lamictal (lamotrigine), Topamax (topiramate), Tegretol (carbamaxepine), and Depakote (valproate). Lyrica, the first FDA-approved medication for fibromyalgia, is in this class. This class of medication shows good benefit in reducing the pain of fibromyalgia and has established itself as potentially the most effective class of medication for migraine prevention. Two of the medications in this class, Topamax and Depakote, are FDA-approved for migraine prevention.Non-pharmacologic treatment includes cognitive behavioral therapy, biofeedback, acupuncture, physical therapy, chiropractic care, and structured exercise programs. Many fibromyalgia patients claim they are “too tired” to exercise. One study showed benefit in exercising for just 10 minutes several times a day. I encourage all my patients to exercise as much as they are able to.Vitamin, herbal and nutritional supplementation may help. The B vitamins are known to be important in stressful conditions and can increase energy. I offer both B-complex & B-12 injections in my office which can potentially boost energy and help lessen the fatigue associated with fibromyalgia. In some cases I recommend a full vitamin & mineral blood panel called SpectraCell which can identify nutritional deficiencies that can be contributing to fatigue and pain. Once the deficiencies are identified, the patient can be instructed on which supplements are needed. I am presently consulting with a local chiropractor, Dr. Di Siena, who offers an integrative program known as First Line Therapy to help patients optimize their well-being from chronic conditions like fibromyalgia.Promising new treatment includes transcranial magnetic stimulation (TMS). This is done in an out-patient setting, is safe & non-painful, is done in a series of treatments, and has been found to be helpful in treatment resistant depression, anxiety and fibromyalgia. Another new treatment is low dose naltrexone. Naltrexone is a medication that has been used clinically for >30 years to treat opioid addiction. More recently, it has been tested in several clinical trials for fibromyalgia and showed a 30% improvement in symptoms compared to placebo. In addition, it was very well tolerated in these studies and is relatively inexpensive.In summary, fibromyalgia can be a very disabling and frustrating medical condition. However, a good integrative approach that combines traditional pharmacological treatment and non-pharmacologic treatment can be very beneficial even for the most difficult-to-treat patient. I believe that the best treatment for a patient is the one that gives them the greatest relief. I encourage you to set up an appointment to develop a treatment plan that can help you live the quality of life you deserve.Sincerely,
Susan Hutchinson, MD Director-Orange County Migraine & Headache Center
Many of my headache patients ask if Botox would help their headaches. This newsletter will focus on Botox and its role in headache prevention. A patient testimonial will be included. I hope this newsletter will help you decide if Botox makes sense for you.
What is Botox?
Botox is Botulinum Toxin Type A. It is a neurotoxin used for greater than 20 years and is currently FDA approved for eye muscle conditions such as strabismus and blepharospasm and for a neck problem called cervical dystonia. The mechanism of action for these conditions is related to the muscle relaxing properties of Botox. It is not yet FDA approved for migraine or headache prevention; however recent clinical trials show promising results. Two recently completed clinical trials were done exploring the use of Botox for adults suffering from “chronic migraine”, i.e. headaches and/or migraine occurring on 15 or more days/month. The results of these 2 studies showed a decrease in the number of headache and migraine days. Additionally, the quality of life in patients receiving Botox in the studies improved significantly compared to patients receiving placebo injections.
For complete product and prescribing information, go to www.botox.com.
How is Botox injected for headache prevention?
Typically 100 units of Botox are injected in multiple sites over the forehead; around the eyes; the temples; the back of the neck and the upper back. The Botox comes in a 100 unit vial and I mix it with a saline solution prior to injection, yielding a concentration of 2.5 units per .1 cc. Then, I fill 5 small syringes, each containing 20 units of Botox. Very small 30 gauge needles are attached to the syringes and then the Botox is injected. There are certain fixed sites and amounts that I use for every headache patient and these include the forehead; the eye and the temples. The fixed sites require 65 units of Botox. With the remaining 35 units, I can “follow the pain” of where my patients experience most of their pain relative to their headaches and tailor the remaining Botox injections accordingly.
The vial of Botox is mixed fresh for each injection visit. There is no “sharing” of Botox with other patients. Each patient pays for and receives the equivalent of 1 full vial of Botox (100 units). Studies indicate that larger amounts (100-300 units) are required for headache prevention in contrast to cosmetic uses of Botox which often require much less quantity.
What are the risks of Botox injection?
The risks are minimal and include bruising, swelling and pain at the site of injection. There is a very slight risk of eyelid dropping which is reversible. An ice pack is applied prior to the forehead and facial injections which can lessen injection pain and prevent bruising and swelling.
To learn more specifics re: benefits/risks of Botox, click on www.imigraine.net.
How soon does it work?
From my experience, many patients feel almost immediate relief from the muscle tenderness part of their headaches, including the forehead, neck and upper back areas. This is due to the muscle relaxing characteristics of Botox. However, true migraine prevention results are not often evident for 2 weeks. The accepted theory on why Botox works to prevent migraine is that it prevents the release of some of the inflammatory agents that cause migraine such as CGRP and substance P.
How long does it last?
Most patients experience 12-14 weeks of benefit after Botox injection. Many comment they can tell when it starts wearing off by an increase in headache.
What is the cost?
Currently we charge a total of $825.00 for Botox injection. This fee includes 1 full vial of Botox (100 units); all related supplies such as needles and syringes; and the procedure cost. The time for the procedure is 30 minutes. In most cases, you can return to work after your injection.
Our policy is to offer insurance billing for Botox; however, we cannot guarantee it will be covered since it is not FDA-approved for headache prevention and is considered “experimental” and “off-label” by most insurance companies.
Patient Testimonial (a quote from one of Dr. Hutchinson’s patients)
“I am really pleased with the results! I felt a “softening” of the muscle tension in my forehead and the back of my neck right away and that has continued over the past week. As you indicated, it appears that the injections take some time to fully work. My forehead today feels better than it did over the weekend, and my shoulders and neck have not been as tense either. I am very satisfied with the results and feel that Botox can be another “weapon” in my arsenal to prevent migraines.”
How do I know if I am a good candidate for Botox for headache prevention?
If you are currently frustrated with your headaches, then Botox is a strong consideration. It is especially helpful, in my opinion, for those patients who have a muscle tension component to their headache, e.g. a lot of forehead/scalp or neck muscle tightness and tenderness. Also, based on the recent studies by Allergan (the maker of Botox), those with more frequent headaches, especially more than 15 days/month, would be good candidates for Botox injection for headache prevention.
Please call our office 949-861-8717 and set up an office visit to evaluate whether you would be a good candidate for Botox. I will review your current headache management as well as the pattern of your headaches and give you my opinion. If Botox makes sense, it can be ordered and the injections given 1-2 weeks later.
Sincerely,
Susan Hutchinson, MD Director-Orange County Migraine & Headache Center
The FDA just approved a new medication for the acute treatment of migraine. It is called Treximet and is a combination of Imitrex (a migraine specific medication) and Naproxen (an NSAID: Nonsteroidal anti-inflammatory medication). Treximet is the first drug of its kind on the market and represents an advancement in the acute treatment of migraine. It is now available in pharmacies.
Why was this combination brought to market?
To answer this question we need to look at what occurs during a migraine attack. Migraine is a neurovascular event and involves the release of neurochemical transmitters such as CGRP and Substance P. These neurotransmitters cause inflammation and vasodilation of blood vessels surrounding our brain. The triptans (Imitrex; Relpax; Maxalt; Axert; Zomig; Frova; Amerge) prevent the release of these neurotransmitters and in turn, prevents the involvement of the blood vessels. They are most effective in taken early in this process.
We have now discovered another pathway involved in migraine that consists of the production and release of prostaglandin. The NSAIDs (nonsteroidal anti-inflammatory medications) inhibit prostaglandin production and release and include medications such as Motrin, Aleve, Advil, and Naprosyn.
Therefore, it makes sense to combine these 2 drugs to attack the multiple pathways involved in migraine. The combination should potentially be more effective than either agent alone.
Why not just take an OTC NSAID like Aleve or Advil with a triptan?
Taking the NSAID such as Aleve with the triptan may not be as effective. From extensive research studies and clinical trials, a unique pharmacokinetic profile is seen with the combination tablet. The Imitrex portion of the tablet reaches peak levels quickly, providing important initial relief; the Naproxen component of the tablet is delayed and reaches peak levels of concentration later than if given separately. This delayed release of the Naproxen provides the important headache prevention needed as the Imitrex begins wearing off. Therefore, most patients experience initial headache relief within 1-2 hours followed by sustained pain-free results for 24 hours.
Additionally, the combination tablet is convenient and eliminates the need to carry two separate medication bottles. Treximet will be packaged in a quantity of #9 tablets and is in a small container that will easily fit into a woman’s purse, e.g.
Who should not take Treximet?
Anyone who has established coronary or peripheral vascular disease should not take Treimet which contains Imitrex, a triptan medication. If an individual has cardiac risk factors such as high blood pressure of high cholesterol, they should be screened prior to triptan use. Anyone with a history of an allergic reaction of any of the triptan medications should not take Treximet. Anyone with a history of an allergy or contraindication to NSAIDs such avoid the use of Treximet which contains Naproxen, a NSAID. Contraindications would also include gastric ulcer; gastritis/esophagitis; history of gastric by-pass; and someone on Coumadin or other blood thinners. Pregnant women should avoid the use of Treximet. Full prescribing information is available at www.treximet.com.
How do I know if I should switch to Treximet? Answer these migraine treatment questions.*
- Do you want more relief from your migraine medicine?
- Do you ever need more than one dose of your current medicine to treat your migraines?
- Do you ever take more than one medication to relieve a single migraine attack?
If your answer was “yes” to 1 or more of these questions, then you may benefit from Treximet. It may provide more complete relief for your migraine headaches. In addition, you may be less likely to re-dose or rescue compared to your current acute headache treatment. Complete relief of head pain and associated symptoms such as nausea within a 2 hour time period is a reasonable expectation followed by sustained pain free for at least 24 hours.
*Migraine Treatment Questionnaire developed by GlaxoSmithKline Pharmaceutical and recognized by the National Headache Foundation as an effective way to initiate dialogue between healthcare professionals and patients regarding treatment effectiveness. Printed with permission from GSK Pharmaceutical.
How do I know if Treximet better than my current triptan or other acute headache medication? Answer the following questions.
- Are you headache free in 2 hours and back to full function?
- Are there any side-effects on the medication?
- Do you need to re-dose within 24 hours?
- Do you have to rescue with another medication?
- Does the headache stay away completely for at least 24 hours? (Sustained pain-free)
In summary, Treximet is the newest prescription medication on the market for the acute treatment of migraine with or without aura in adults 18 and older. The combination of Imitrex/Naprosyn represents the most migraine specific medication now available. Schedule an appointment with Dr. Hutchinson or your primary care provider to see if Treximet would be right for you.
Sincerely,
Susan Hutchinson, MD Director-Orange County Migraine & Headache Center