Chronic migraine | Headache NewsBlog

Zavegepant, a new abortive migraine drug, is now available

By: Dr. Mauskop

05-07-2023

Chronic migraine, Cluster headaches, Headache medications, New treatments

Zavegepant (Zavzpret), the first CGRP nasal spray for the treatment of acute migraine attacks, was approved by the FDA in March and is now readily available in all US pharmacies..

Zavegepant belongs to the family of CGRP antagonists, which work by blocking excessive amounts of the neurotransmitter CGRP. Elevated levels of CGRP are known to contribute to the development of migraines. By inhibiting its action, zavegepant can effectively stop an ongoing migraine attack. While there are already two oral CGRP medications for the acute treatment of migraines (Nurtec and Ubrelvy), zavegepant is the first nasal spray option. Nasal sprays offer several advantages, including faster onset of action compared to tablets and the ability to bypass the stomach. These benefits are particularly valuable for individuals experiencing migraines accompanied by nausea and vomiting.

Clinical studies have demonstrated that zavegepant is superior to placebo in promptly eliminating all pain and the most bothersome symptom within two hours of administration. The most commonly reported bothersome symptoms associated with migraines are nausea, sensitivity to light (photophobia), and sensitivity to noise (phonophobia).

Side effects of zavegepant were generally mild and infrequent. Participants in clinical trials noted an unpleasant taste in 18% of cases, compared to 4% in the placebo group. Additional side effects included nausea (4% vs. 1%), nasal discomfort (3% vs. 1%), and vomiting (2% vs. 1%). Taste-related issues have been observed with other nasal sprays used for migraines, particularly among patients who experience nausea. However, this can be easily addressed by sucking on a hard candy while using the nasal spray.

Interestingly, even individuals who did not respond to other CGRP drugs may potentially benefit from zavegepant. While these drugs are similar in their mechanism of action, they are not identical, and patients often exhibit strong preferences for a particular medication within the same category. This preference phenomenon is common in other migraine drug categories such as triptans, NSAIDs, and oral CGRP drugs.

Effects of observational learning on placebo responses, or why sham remedies seem to work so well

By: Dr. Mauskop

19-06-2023

Alternative Therapies, Brain disorders, Chronic migraine, Pain, Pain Research, Psychology of headaches

Many companies selling ineffective treatments for painful conditions manage to attract a large customer base by showcasing testimonials from satisfied customers. Recent research suggests that these individuals might genuinely benefit from hearing others express positive experiences.

A study published in the journal Pain, titled “Learning pain from others: a systematic review and meta-analysis of studies on placebo hypoalgesia and nocebo hyperalgesia induced by observational learning” explores the impact of observational learning on placebo and nocebo responses.

Placebo hypoalgesia refers to when a fake treatment (placebo) reduces pain, while nocebo hyperalgesia is when the placebo actually increases pain. Learning processes, such as classical conditioning and operant conditioning, have been shown to play a role in these effects. Verbal suggestions and observational learning from others also influence placebo and nocebo responses. However, the magnitude of these effects can vary depending on the specific learning process used.

This meta-analysis of 17 studies showed that observational learning can effectively modulate pain and pain expectancies. However, the magnitude of these effects varies across studies. Observing a model in person resulted in larger effects compared to observing a videotaped model. The analysis also suggested that placebo effects can be induced through observational learning, but nocebo effects were not consistently observed. Empathy, specifically the empathic concern component, was found to be associated with the magnitude of observational learning effects.

The article concludes that observational learning can indeed influence pain experience and pain expectancies. Further studies possibly could lead to methods to enhance the treatment effects of proven therapies.

PTSD biomarkers

By: Dr. Mauskop

12-06-2023

Alternative Therapies, Brain disorders, Chronic migraine, Head trauma, Headaches, post-traumatic headache, Psychology of headaches

Researchers have identified four blood biomarkers that show promise in predicting, diagnosing, and monitoring treatment response for posttraumatic stress disorder (PTSD). These biomarkers could lead to more accurate methods of screening for PTSD, allowing for early intervention and prevention strategies. Additionally, they could help monitor treatment progress, identify different subtypes of PTSD, and enhance our understanding of the underlying mechanisms of the disorder.

The study was conducted by the PTSD Systems Biology Consortium, initiated by the Department of Defense, and involved approximately 45 researchers. The team analyzed blood samples from 1,000 active-duty Army personnel from the Fort Campbell Cohort (FCC), who were assessed before and after deployment to Afghanistan in 2014.

The researchers focused on four biomarkers: glycolytic ratio, arginine, serotonin, and glutamate. They categorized the participants into four groups based on their PTSD symptoms, resilience levels, and clinical assessments. The findings revealed that individuals with PTSD or subthreshold PTSD had higher glycolytic ratios and lower arginine levels compared to those with high resilience. Additionally, participants with PTSD exhibited lower serotonin and higher glutamate levels. These associations were independent of factors such as age, gender, body mass index, smoking, and caffeine consumption.

The study results require further validation. The researchers also aim to determine the optimal time to screen soldiers for PTSD, considering the psychological challenges that arise around 2 to 3 months post-deployment. Moreover, they recognize the need for gender-specific biomarkers to improve the clinical assessment of female soldiers, given the increasing number of women serving in combat roles.

Ultimately, these findings may apply to the civilian population experiencing PTSD.

Weather and headaches – AI confirms the connection

By: Dr. Mauskop

05-06-2023

Alternative Therapies, Chronic migraine, Headache medications, Headaches, Migraine, Science of Migraine

The fact that certain types of weather can trigger headaches is not news to many migraine sufferers. Many researchers have investigated this relationship, but the findings have been inconsistent. The reported weather triggers range from humidity and strong winds to heat, cold, and barometric pressure changes.

In a recent study, Japanese researchers analyzed data collected from a smartphone app used by 4,375 individuals who experience headaches. By employing statistical and deep learning models, they aimed to predict the occurrence of headaches based on weather factors. The results of their study have been published in Headache, the journal of the American Headache Society.

The research confirms that headaches are more likely to occur under specific weather conditions. Low barometric pressure, barometric pressure changes, higher humidity, and rainfall were identified as factors associated with a higher occurrence of headaches.

This finding is not just a matter of curiosity; it has practical implications. There are several options besides moving to a place with a consistently mild climate, such as Southern California. For instance, low barometric pressure headaches can sometimes be prevented with the use of acetazolamide (Diamox), a medication commonly prescribed for mountain sickness. Setting up a Google Alert or using an app like WeatherX can provide warnings when barometric pressure drops. This allows individuals to take preemptive measures such as taking acetazolamide to prevent a headache the following day. Adopting general measures such as regular exercise, meditation, a healthy diet, and sufficient sleep can also help mitigate the effects of weather-related headaches.

Antidepressant use during pregnancy

By: Dr. Mauskop

30-04-2023

Brain disorders, Chronic migraine, Headache medications, Headaches, Headaches in children, Migraine, Pain, Psychology of headaches

Antidepressants are commonly prescribed to treat migraines, tension-type headaches, and various types of chronic pain. Migraines primarily affect women of reproductive age, and those who suffer from migraines are more likely to develop anxiety and depression compared to those without migraines. This may be another reason why someone with migraines might be prescribed an antidepressant. Women who are pregnant or planning to become pregnant are understandably cautious about taking any medication.

Antidepressant use during pregnancy does not increase the risk of neurodevelopmental disorders in children, according to a new study published in JAMA Internal Medicine.

Antidepressant use during pregnancy has been associated with neurodevelopmental disorders in children in some studies. However, other factors such as the parent’s mental health status, genetics, and environmental factors may have influenced these results. The objective of this study was to evaluate the association between antidepressant use in pregnancy and neurodevelopmental outcomes in children.

The study looked at data from over 3 million pregnancies, tracking children from birth until outcome diagnosis, disenrollment, death, or the end of the study (maximum 14 years). There were 145,702 antidepressant-exposed pregnancies.

The study found no evidence to suggest that antidepressant use in pregnancy itself increases the risk of neurodevelopmental disorders such as autism spectrum disorder, attention-deficit/hyperactivity disorder, specific learning disorders, developmental speech/language disorders, developmental coordination disorders, intellectual disabilities, or behavioral disorders.

However, given the strong crude associations found in previous studies, antidepressant exposure during pregnancy may be an important marker for the need for early screening and intervention to modify factors that do increase such risk.

How long to rest after a concussion

By: Dr. Mauskop

03-04-2023

Botox, Brain disorders, Chronic migraine, Head trauma, Headaches, Migraine

The traditional approach for managing concussions has been to recommend rest until post-concussion symptoms resolve. While many neurologists still advocate for this approach, several studies have suggested that an early return to activity after a concussion may lead to better outcomes.

Most pediatric guidelines recommend 24 to 48 hours of physical and cognitive rest, followed by a gradual return to school with support and accommodations.

The latest pediatric study was done in Canada. It examined data for 1630 children aged 5 to 18 with a mean age of 12 and of whom 38% were girls. The primary outcome was symptom burden at 14 days, measured with the Post-Concussion Symptom Inventory. Missing fewer than 3 days after concussion was defined as an early return to school.

An early return to school was associated with a lower symptom burden 14 days postinjury in the 8 to 12-year and 13 to 18-year age groups, but not in the 5 to 7-year age group.

Prolonged periods of complete physical and cognitive rest lasting one to two weeks can be detrimental, as it can be challenging for many people to remain inactive for such an extended period. This approach, which involves refraining from activities such as reading, writing, screen time, and exercise, can lead to depression, increased anxiety, and may even delay recovery.

After a brief period of rest lasting 24 to 48 hours, I typically recommend a gradual return to full activities. The key is to monitor for any exacerbation of post-concussion symptoms such as headaches, dizziness, brain fog, or fatigue. If an activity does not worsen symptoms, patients can continue to increase the level of physical and cognitive activities at a steady pace.

The top 10 non-drug therapies for migraines

By: Dr. Mauskop

27-03-2023

Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine, neurostimulation, Psychology of headaches

Most people are right in not wanting to take medications. They can have serious or just very bothersome side effects, they help only some people and can be expensive. Fortunately, there are many ways to control migraines without drugs. Here are the top 10 non-drug therapies for migraine headaches among several dozen described in my book, The End of Migraines: 150 Ways to Stop Your Pain.

Non-drug therapies

Aerobic exercise
Meditation
Magnesium
CoQ10
Cognitive-behavioral therapy
Acupuncture
Nerivio
Cefaly
Riboflavin
Boswellia

The Top 10 Prophylactic Treatments for Migraines

By: Dr. Mauskop

20-03-2023

Botox, Chronic migraine, Headache medications, Migraine

In a recent post, I listed the top 10 acute treatments for migraine attacks that are mentioned in my book, The End of Migraines: 150 Ways to Stop Your Pain. Here is a list of the top 10 preventive drug therapies for migraines. In the next post, I will list the top 10 non-drug therapies.

The order of choices can vary depending on co-morbidities, potential side effects, cost, and other factors. For example, patients with coexistent anxiety and/or depression would have duloxetine and nortriptyline move higher on this list. Patients with rapid heartbeat, anxiety, or PTSD could start with nebivolol. Those with high blood pressure, could start with candesartan or nebivolol, and so on.

OnabotulinumtoxinA (Botox)
Atogepant (Qulipta)
Rimegepant (Nurtec)
Galcanezumab (Emgality)
Nebivolol (Bystolic)
Propranolol (Inderal)
Candesartan (Atacand)
Duloxetine (Cymbalta)
Nortriptyline (Pamelor)
Fremanezumab (Ajovy)

Thank you for making The End of Migraines #1 Bestseller in Nervous System Diseases

By: Dr. Mauskop

14-03-2023

Alternative Therapies, Blocks, Botox, Brain disorders, Chronic migraine, Headache medications, Headaches, Migraine, Migraine in pregnancy, Psychology of headaches, Science of Migraine

A new migraine drug and my top 10 acute treatments for migraines

By: Dr. Mauskop

13-03-2023

Chronic migraine, Headache medications, Headaches, Migraine

Zavegepant nasal spray (Zavzpret) was just approved by the FDA for the acute treatment of migraines. It belongs to the family of gepants. These drugs abort migraine attacks by blocking the CGRP receptor. CGRP (calcitonin gene-related peptide) is released during a migraine attack. Blocking this molecule or the receptor it attaches to relieves migraines in about 50% of people.

There are four CGRP monoclonal antibodies, or mAbs, that are injected once every one or three months to prevent migraine attacks. Gepants are taken by mouth. Two of them – ubrogepant (Ubrelvy) and rimegepant (Nurtec) – are approved for the acute treatment of migraine attacks. Rimegepant, along with atogepant (Qulipta), is also approved for the prevention of migraines.

Nasal sprays to treat migraines have the advantage of faster onset of action. They are particularly useful for people who have nausea or vomiting and have difficulty absorbing or holding down oral medications. Other migraine drugs in a nasal spray include sumatriptan, zolmitriptan, dihydroergotamine, and ketorolac. For patients for whom these older drugs are ineffective, cause side effects, or are contraindicated, zavegepant could be a very good option.

If there are no contraindications for the use of a triptan (e.g. heart or other vascular diseases), I would use sumatriptan first because of the cost. It is also likely that insurance companies will require that the patient fails sumatriptan before they agree to pay for a new and more expensive drug. This is what they usually require before paying for oral gepants.

Here is a list of what I consider to be the top 10 acute medications to treat migraine from the second edition of my book, The End of Migraines: 150 Ways to Stop Your Pain. I might add zavegepant to the next edition of this book.

Sumatriptan
Rizatriptan
Eletriptan
Naratriptan
Zolmitriptan
Rimegepant
Ubrogepant
Aspirin/caffeine/acetaminophen
Naproxen
Ibuprofen

Attend the Migraine World Summit!

By: Dr. Mauskop

09-03-2023

Alternative Therapies, Botox, Chronic migraine, Headache medications, Headaches, Migraine

I am honored to speak at this year’s Migraine World Summit on Sunday, March 12. My topic is Safety Update: DHE, Triptans, Magnesium, Butterbur, and more.

The Migraine World Summit gives you a chance to improve your understanding of migraine headaches. 2023 dates: March 8-16. Register for free access at MigraineWorldSummit.com Call: 8885256449, Email: info@migraineworldsummit.com Facebook: www.facebook.com/MigraineWorldSummit/ Instagram: @migrainesummit

Predicting response to migraine treatment

By: Dr. Mauskop

05-03-2023

Chronic migraine, Headache medications, injections, Migraine

Updated on 3/5/23

Even the best migraine medications work for only about half of the people who try them. In the next decade or so, advances in pharmacogenomics, neuroscience, and artificial intelligence will allow us to predict who is going to respond to which drug. This will eliminate the trial-and-error approach we have to use now.

German researchers led by Dr. Uwe Reuter just published a study that attempts to predict who is going to respond to injections of CGRP monoclonal antibodies (mAbs) that are used for the prevention of migraines. These drugs include erenumab (Aimovig), galcanezumab (Emgality), and fremanezumab (Ajovy). The fourth drug in this family that is given intravenously, eptinezumab (Vyepti) was not available in Germany at the time of the study.

They compared super-responders (patients with 75% or greater reduction of monthly headache days) with non-responders (patients with 25% or lower reduction of monthly headache days after trying all three mAbs). Of 260 patients with chronic and episodic migraine they evaluated, 11% were super-responders, and 10% were non-responders.

Non-responders were more likely to have chronic migraines. Super-responders were significantly more likely to report good improvement of their acute migraine headache with a triptan. Non-responders were more likely to have depression and overuse acute medications.

It was interesting that only 10% of patients were non-responders. The authors explained this by the fact that they had to fail all three mAbs to be considered non-responders. An earlier German study showed that one-third of patients who did not respond to erenumab did respond to galcanezumab or fremanezumab.

The low number of super-responders to mAbs could be due to the fact that the German government pays for this treatment only if there is treatment failure or intolerable adverse events with all first-line preventives (beta-blockers, topiramate, flunarizine, amitriptyline and for chronic migraine, also OnabotulinumtoxinA, or contraindications to those. In the large clinical trials that led to the approval of mAbs, there was no such requirement and the results were much better.

Another study recently published by Sait Ashina and others in Rami Burstein’s group at Harvard showed that people who have increased skin sensitivity between migraine attacks (allodynia) are more likely to respond to galcanezumab.

These studies describe only trends and at this time have limited practical application. Patients who are depressed, overuse acute drugs, suffer from chronic migraines, or have interictal allodynia may still respond to mAbs. This information, however, may lead to more accurate prediction models when it is combined with genetic, imaging and other new data.