May | 2020 | Headache NewsBlog

I’ve tried Ubrelvy (ubrogepant) and Nurtec ODT (rimegepant)

By: Dr. Mauskop

30-05-2020

Chronic migraine, Headache medications, Migraine, New treatments

My migraines respond very well to sumatriptan, but I do like to try new treatments that I recommend to my patients.

A few months ago two new abortive drugs to treat acute migraine attacks were approved by the FDA. Ubrelvy (ubrogepant) and Nurtec ODT (rimegepant) block CGRP, a substance released during a migraine attack. They work in a similar way to four injectable drugs used for the prevention of migraines – erenumab (Aimovig), fremanezumab (Ajovy), galcanezumab (Emgality), and eptinezumab (Vyepti). I’ve tried erenumab and fremanezumab with some relief, but stopped both because sumatriptan works well and I don’t really need any preventive medications.

Because the two injectable drugs did help, I expected the two new oral medications to work as well. Alas, neither one had any effect. This suggests that CGRP is not very operational in my case. The fact that sumatriptan, a drug that works on serotonin receptors works so well indicates that the serotonin system is dominant in producing my migraines.

Migraine is a very heterogeneous disorder with a variety of clinical presentations and with dozens of identified genetic abnormalities that predispose one to migraines. This means that we are not likely to have a drug that works for all migraine patients. What we do expect, is the advent of personalized medicine – having tests that predict which drug will work for which patient.

Eye exercises for head trauma and headaches

By: Dr. Mauskop

22-05-2020

Alternative Therapies, Head trauma, Headaches, Migraine

We recently started using RightEye eye-tracking equipment which can help our patients who are suffering from visual difficulties due to migraines, concussion, or traumatic brain injury (TBI). Many brain disorders can impair the control of eye movements. This can lead to incorrect information being passed from the eyes to the brain, which can worsen brain dysfunction. Eye strain can also contribute to migraines and post-concussion headaches.

The RightEye computer has a built-in infrared eye-tracking device that can accurately diagnose different abnormal eye movements. It tests smooth pursuit, vertical and horizontal saccades, reading, reaction time, and other functions. A recent study, Vertical smooth pursuit as a diagnostic marker of traumatic brain injury showed a correlation between moderate and severe TBI and abnormal eye movements.

Eye movement problems after TBI were also reported in a study published in the Journal of Neurotrauma , Eye Tracking Detects Disconjugate Eye Movements Associated with Structural Traumatic Brain Injury and Concussion.

A study in the journal Brain showed that eye movement difficulties were still present 3 to 5 months after the concussion and that they were not affected by the presence of depression or degree of intellectual ability. Compared with neuropsychological tests, eye movements were more likely to be markedly impaired in patients with many postconcussion symptoms.

While there are no studies showing that migraines improve with eye exercises, there is some evidence that symptoms of concussion which can include migraine headaches, do improve. A review of several published studies of vision therapy for post-concussion symptoms found it “promising”.

Why would we offer this eye movement therapy in the absence of definitive proof of its efficacy? Mostly because there are limited options for the treatment of concussion and migraines with prominent visual symptoms. We also consulted experts at SUNY College of Optometry in NYC and they were very positive about the potential benefits of this therapy.

The testing process takes about 10 minutes. If problems are found, patients are prescribed specific eye exercises that are done daily by logging into RightEye company’s portal.

More on vitamin D and COVID-19

By: Dr. Mauskop

14-05-2020

Uncategorized

The evidence is growing that those with low vitamin D levels are at a higher risk for respiratory infections, including COVID-19. However, purists argue that we need more evidence and better evidence from randomized trials. This is quite irresponsible considering that we have so much correlational data and that the risk of taking vitamin D is minuscule. You can read some of the debates on this question in the recent issue of the Irish Medical Journal.

As I mentioned in a recent post, it is important to keep your vitamin D level not only in the normal range, which in most laboratories is between 30 and 100, but at least in the middle of this range.

One piece of supporting evidence is the fact that patients with multiple sclerosis (MS) whose vitamin D level is in the bottom quartile of the normal range are four times more likely to have a flare-up of their MS than those in the top quartile. Another MS study showed “…profound association of 25(OH)D levels with MRI measures of disease activity and progression” Those with vitamin D deficiency were also found to have higher risk of developing Alzheimer’s disease.

The above-mentioned evidence is not necessarily transferable to respiratory infections, however, multiple sclerosis is an autoimmune inflammatory condition, while Alzheimer’s has an inflammatory component and it is possible that inflammation could be where vitamin D exerts its beneficial effect.

So the debates need to end and everyone should take at least 50 mcg (2,000 units) of vitamin D. An important fact to keep in mind is that some people do not absorb vitamin D well so if you were found to be deficient, it is a good idea to recheck your level since you may need to increase the dose.

100 Migraine Drugs, A to Z: phenelzine

By: Dr. Mauskop

13-05-2020

Chronic migraine, Headache medications, Migraine

Phenelzine (Nardil) is an antidepressant which was approved by the FDA for the treatment of depression in 1961. It belongs to the family of monoamine oxidase (MAO) inhibitors and it is a very effective antidepressant. However, it is rarely used because of its potential to cause side effects and serious drug and food interactions.

There have been no good trials of phenelzine for the treatment of migraines. One small study compared phenelzine with and without a beta blocker, atenolol. Atenolol is known to help migraines and lowers blood pressure, so it could prevent an increase in blood pressure from phenelzine. Phenelzine worked well with and without atenolol. Another report described 11 patients with refractory (not responding to usual drugs) migraines. Ten of the 11 patients had a greater than 50% reduction in the number of headache attacks. Two patients developed low blood pressure and one, high pressure, which was easily controlled. There was also a case report of dramatic improvement in a patient with chronic and treatment-resistant migraines.

Phenelzine can interact with other antidepressants, appetite suppressants, drugs for attention deficit disorder, some epilepsy drugs, muscle relaxants, certain blood pressure medications, some opioid (narcotic) medications, and other. Foods that can interact with phenelzine include aged cheeses, aged/dried/fermented/salted/smoked/pickled/processed meats and fish, fava beans, Italian green beans, broad beans, overripe or spoiled fruits, packaged soups, sauerkraut, red wine, and some other types of alcohol.

An adverse interaction with these drugs and foods can cause a sudden increase in blood pressure or serotonin syndrome, which can be dangerous. However, it does not mean that every drug and food listed above will always cause a serious reaction. Most people will have mild or no reaction at all and if another drug needs to be added to phenelzine, it can be started at a very low dose, and then the dose can be slowly increased.

Besides drug and food interactions, phenelzine has some unpleasant side effects of its own. These include drowsiness, dizziness, constipation, dry mouth, weight gain, sexual dysfunction, and other.

We have many other antidepressants (tricyclics and SNRIs) and other categories of drugs (CGRP drugs, Botox, epilepsy and high blood pressure medications) that are very effective for the prevention of migraines, so phenelzine is almost never used. I prescribe it only after trying many other preventive drugs but it works exceptionally well for a handful of patients for whom no other drug helps.

100 Migraine Drugs, A to Z: ondansetron

By: Dr. Mauskop

06-05-2020

Headache medications, Migraine

Ondansetron (Zofran) is not a migraine drug per se, but it is used for the treatment of nausea that often accompanies a migraine attack. It belongs to a different class of nausea drugs than the older drugs such as prochlorperazine (Compazine), promethazine (Phenergan) or metoclopramide (Reglan). which are effective for both nausea and pain of migraine.

There are no good studies of ondansetron for the treatment of migraines, but the impression of most headache specialists is that it is helpful only for the treatment of nausea of migraine and not the pain. However, one large observational study does suggest that it may help more than just nausea, at least in children. Observational studies are much less reliable than double-blind placebo-controlled ones, however, the large size of this study provides some compensation for this deficiency. The researchers looked at the records of 32,124 children with migraine who presented to the emergency room. One fifth received ondansetron and it was as effective in preventing a return visit to the ER as metoclopramide, while prochlorperazine was a bit more effective.

The advantage of ondansetron is that it does not cause neurological symptoms of restlessness (akathisia) and drowsiness, which can occur with metoclopramide and prochlorperazine.

Ondansetron is available in a tablet, an orally disintegrating tablet, and as an injection, but not as a suppository. Rectal suppositories of prochlorperazine and promethazine work fast and are very useful for patients who are vomiting and cannot hold down a tablet.

I’ve tried Ubrelvy (ubrogepant) and Nurtec ODT (rimegepant)

Eye exercises for head trauma and headaches

More on vitamin D and COVID-19

100 Migraine Drugs, A to Z: phenelzine

100 Migraine Drugs, A to Z: ondansetron

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