Chronic migraine | Headache NewsBlog

Daxxify, a new Botox competitor

By: Dr. Mauskop

08-09-2022

Alternative Therapies, Botox, Chronic migraine, Headache medications, Headaches, Migraine, New treatments, Pain

No, Daxxify is not really a competitor in the treatment of chronic migraines or any other medical condition. Daxxify, a new botulinum toxin, was just approved by the FDA only for cosmetic use. Daxxify does stand out from five other botulinum toxin brands in that its effect lasts longer. The other toxins are Xeomin, Dysport, Jeuveau, and Myobloc. Myobloc is approved only for medical conditions, Jeuveau only for cosmetics, and Xeomin and Dysport are approved for both cosmetics and a few medical conditions.

Initially, Botox was approved by the FDA in 1989 to treat eye problems. Since then, it has been approved for many medical and cosmetic indications, including chronic migraine. None of the other toxins are approved for such a wide range of indications. It remains by far the most widely used type of botulinum toxin with tens of millions of people treated for medical and cosmetic reasons.

Yes, having a longer-acting botulinum toxin is an advantage. You will need to have less frequent treatments. However, if you have any side effects, they will also take longer to go away. We are talking mostly about cosmetic side effects, such as droopy eyelids. When treating headaches, with proper technique, side effects are uncommon. These may include weakness of the neck muscles or, if treating TMJ syndrome, difficulty chewing.

Since Botox is approved by the FDA for chronic migraines, Botox is the drug insurance companies cover. Allergan (a division of Abbvie), the manufacturer of Botox, has many more years left on their patent to treat chronic migraines. Botulinum toxin is a biological product (made by bacteria rather than synthesized from chemicals) and every version of it is slightly different. This is why when Allergan’s patent to treat migraines expires, the competitors will have to conduct large trials to prove that their product is also effective for migraines.

Post-COVID headaches

By: Dr. Mauskop

19-08-2022

Brain disorders, Chronic migraine, Headaches

Headache is a common symptom of any infectious illness, including COVID. A group of Spanish researchers analyzed six published studies of headaches in adult Spanish COVID patients.

According to their review, headache is an early symptom of COVID. It typically lasts two weeks. Patients in these studies were followed for up to a year. One out of five patients had developed a headache that persisted for at least a year. Women and older patients were more likely to be affected. This persistent headache most often resembled chronic migraine. The pain was throbbing with associated sensitivity to light and noise, and worsening with physical activity. The authors did not observe a difference between patients with and without prior history of headache. Patients with more intense headaches were more likely to develop a chronic headaches.

The published studies reviewed by the authors did not address the treatment of headaches. Considering that the persistent headaches resembled migraines, we tend to treat them as we do chronic migraines. This means the use of antidepressants, epilepsy drugs, blood pressure medications, Botox, triptans, and CGRP drugs (both oral and injectable). It is likely that with early and aggressive treatment, many patients would not have headaches persist for such a long time. Doctors in Europe are less likely to prescribe medications and use Botox in headache patients than we are in the US.

COVID vaccination also carries a risk of developing persistent headaches. As mentioned in a previous post, people who received Pfizer or Oxford-AstraZeneca vaccine were twice as likely to develop a headache as those who received the placebo. The headache in these patients also tended to resemble migraine.

Magnesium and migraines – an interview with Dr. Amelia Scott Barrett

By: Dr. Mauskop

11-07-2022

Alternative Therapies, Chronic migraine, Migraine, Science of Migraine

Last week I spoke to Dr. Amelia Scott Barrett, a neurologist and headache specialist based in Denver. She shares my interest in combining medications with various non-drug therapies. In our first conversation, we discussed the role of magnesium in treating migraines.

The 6th Annual International Headache Symposium in Israel

By: Dr. Mauskop

06-07-2022

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

The 6th Annual International Headache Symposium in Israel will be held at Daniel Hotel, Herzliya (8 miles from Tel Aviv), on October 27, 2022. THe symposium is organized by the President of the Israeli Headache Association, Dr. Oved Daniel and by Dr. Arieh Kuritzky.

I am honored to have been invited to speak alongside the President of the International Headache Society Dr. Messoud Ashina, Dr. Rami Burstein of the Harvard Medical School, and other leading headache experts. The topic of my presentation will be “What to do when nothing works”. Other topics to be discussed include, Molecular signaling pathway in migraine: update, (Messoud Ashina), Connecting the line between dizziness, occipital headache, muscle tenderness and the cerebellum (Sait Ashina), Open-label studies: do they have any value? (Cristina Tassorelli), and others.

You can see the full program and registration information on this website.

Acute migraine therapy in pregnancy – triptan is the safest choice.

By: Dr. Mauskop

20-06-2022

Chronic migraine, Headache medications, Migraine, Migraine in pregnancy

Two out of three women stop having migraines during pregnancy, especially in the second and third trimester. The difficult question is how to treat migraines in the first trimester and in women whose migraines do not improve or get worse in pregnancy.

Acetaminophen (Tylenol, paracetamol) is considered safe in pregnancy and that is what many women take for migraines and other pains. Unfortunately, acetaminophen is usually ineffective for severe migraines. It is also not as safe as many physicians and the general public thinks. Several studies indicate that acetaminophen increases the risk of attention-deficit hyperactivity disorder (ADHD) and with heavy use, possibly even autism spectrum disorder.

Some obstetricians strongly advise against taking any migraine medications. However, the stress of an acute migraine attack with severe pain, vomiting, and dehydration is likely to have a deleterious effect on the fetus. A Danish study of 22,841 pregnancies among women with migraine showed that untreated migraine leads to an increased risk of low birth weight, preterm birth, and cesarean delivery.

A report just published in the journal of the American Medical Association (JAMA) examined “Association of Maternal Use of Triptans During Pregnancy With Risk of Attention-Deficit/Hyperactivity Disorder in Offspring”.

The study used the data from the Norwegian Mother, Father and Child Cohort Study, linked to the Medical Birth Registry of Norway, the Norwegian Patient Registry, and the Norwegian Prescription Database using the mother’s personal identification number. The conclusion of this large and rigorous study was: “This cohort study found no association between prenatal triptan exposure and ADHD diagnosis or ADHD symptoms at 5 years of age. This study adds to the growing literature on the safety of triptan use during pregnancy and expands it to an important neurobehavioral outcome.”

Triptans have been available without a prescription in all European countries for over a decade. In the US, triptans are available only by prescription. This is one of the reasons for the perception of acetaminophen as being more benign than sumatriptan and other triptans. The opposite is likely to be true. If you are a pregnant woman suffering from severe migraines, ask your doctor for a prescription for sumatriptan.

Cove presents its data on the efficacy of telemedicine in treating migraines

By: Dr. Mauskop

11-06-2022

Alternative Therapies, Chronic migraine, Headaches, Migraine

With tens of millions of Americans suffering from migraines, access to care is a major problem. Cove, a telemedicine startup, offers a practical and affordable solution. They deliver evidence-based therapies to patients in need. To prove that their approach works, Cove collects and analyzes vast amounts of data. The study I just presented at the annual scientific meeting of the American Headache Society shows that with Cove underserved minorities obtain excellent outcomes that are equal to those of whites.
Disclosure: I am a paid consultant to Cove.

Triptans are safe even in those with cardiovascular conditions – a new report

By: Dr. Mauskop

10-06-2022

Chronic migraine, Headache medications, Migraine

A paper presented at the annual meeting of the American Headache Society that is taking place this weekend examined the risk of major adverse cardiovascular events (MACE) in patients with preexisting cardiovascular (CV) conditions. The researchers compared the risk of triptans with that of opioid/barbiturate drugs (drugs like codeine, Vicodin, Percocet, Fioricet) and non-steroidal anti-inflammatory drugs (NSAIDs).

They used Mass General Brigham Research Patient Data Registry database to identify 12,121 prescriptions. Of these, 33% were for triptans, 50% for opioid/barbiturate drugs, and 17% for NSAIDs.

MACE occurred in 1% of those taking triptans, 4.5% taking opioid/barbiturate drugs, and 3.8% taking NSAIDs.

This goes against the established dogma of avoiding triptans in patients with CV problems. Instead, doctors are advised to offer opioid/barbiturate drugs or NSAIDs. Unfortunately, according to the FDA-approved package insert, triptans are contraindicated in patients with CV, cerebrovascular, and peripheral vascular problems. This contraindication came about from purely theoretical reasoning rather than real-life experience. Triptans do in fact have mild vasoconstriction properties and it is possible that someone with severe occlusion of coronary or other blood vessels can have dangerous constriction of a blood vessel. There have been also reports of healthy people developing cardiovascular complications, but those are very rare.

This new data indicates that triptans are safer than the alternatives most doctors prescribe. The two alternatives described in the report also carry significant risks of addiction, stomach ulcers, and bleeding. It is very likely, however, that doctors will continue to avoid prescribing triptans in this population because of legal concerns and ingrained habits.

We do have two new classes of drugs to treat an acute migraine attack that are proven to be safe in patients with CV conditions. These are gepants – rimegepant (Nurtec) and ubrogepant (Ubrelvy) as well as ditans – lasmiditan (Reyvow). These drugs are very expensive and insurers always require that patients first try other drugs.

Another study confirms vascular safety of triptans

By: Dr. Mauskop

04-06-2022

Chronic migraine, Headache medications

Sumatriptan (Imitrex) and other triptans have been available without a prescription in all European countries for over a decade. A new study by Austrian researchers published in the current issue of Headache confirms the outstanding safety of these drugs.

The study looked at 13,833 people over 50 years of age who were prescribed a triptan in 2011, the year before triptans became available over-the-counter. The comparison group included 41,400 triptan non-users. Of the 13,833, 19% were older than 65. The researchers established that 16% “overused” triptans, defined as getting more than 30 doses in a 90-day period, although the concept of “overuse” clearly lacks a scientific basis.

They discovered that those who were taking triptans did not spend more time in a hospital. They also did not have a higher frequency of heart attacks, hypertension, irregular heartbeats (arrhythmias), strokes, circulation problems in their extremities, or other vascular problems. This was true even for those who “overused” triptans.

These findings are consistent with the “Consensus Statement: Cardiovascular Safety Profile of Triptans in the Acute Treatment of Migraine” by the Triptan Cardiovascular Safety Expert Panel published in 2004. It states “The incidence of serious cardiovascular events with triptans in clinical trials and clinical practice appears to be extremely low “.

Unfortunately, in the US triptans are available only by prescription. About 15 years ago, the FDA blocked an application by the American Home Products (a company that Pfizer later acquired) to launch over-the-counter sumatriptan. This greatly restricts access to a highly effective and safe migraine drug. Many physicians remain under the impression that triptans cause heart attacks, strokes, and other dangerous side effects. My patients often tell me that this is what their previous doctor warned them about.

It is clear that triptans are safer than Excedrin, aspirin, ibuprofen, or naproxen. Several dozen of my patients have been taking triptans daily for years. They do not have medication overuse headaches, do not suffer any long-term side effects, and do enjoy disability-free life.

CGRP monoclonal antibodies in pregnancy

By: Dr. Mauskop

09-05-2022

Chronic migraine, Headache medications, injections, Migraine, New treatments

Not surprisingly, none of the new migraine drugs have been tested in pregnant women. No new drug for any indication is ever tested for its safety in human pregnancy. They are always tested in pregnant animals, which helps weed out most drugs that are clearly dangerous. It takes decades to learn if a drug is safe. This happens through an accumulation of anecdotal reports and pregnancy registries that are usually run by drug manufacturers.

Erenumab (Aimovig) was the first CGRP monoclonal antibody to be approved for the preventive treatment of migraines four years ago. It was tested in pregnant monkeys who were given 50 times higher doses (by weight) than the FDA-approved dose for humans. Even though some of the medicine crossed the placenta into baby monkeys, they had no developmental problems.

In the current issue of Headache, University of Texas doctors published a report of a woman who continued to inject herself with erenumab throughout the duration of her pregnancy. She tried to stop the drug before planning to get pregnant but her severe migraines recurred. Her baby was born healthy and had normal development by the last evaluation at 6 months of age.

This case report is the first very small but important step in the process of evaluating the safety of erenumab in pregnancy.

In humans, the transfer of antibodies, which are large molecules, across the placenta is very limited before the 16th week of pregnancy and increases after the 22nd week. We still recommend stopping the drug about five months before a pregnancy is planned. If a woman, however, does get pregnant, intentionally or not, the risk of complications is low if erenumab is stopped within the first three months of pregnancy. This also applies to all other monoclonal antibodies in general and specifically other migraine drugs – galcanezumab (Emgality), fremanezumab (Ajovy ), and eptinezumab (Vyepti).

What to do if Emgality, Aimovig, and Ajovy do not last a full month

By: Dr. Mauskop

14-04-2022

Chronic migraine, Migraine, New treatments

Yesterday I saw a 48-year-old man who has been suffering from migraine headaches since his teens. He did not respond to a wide variety of drugs and non-drug therapies, but Emgality has been very effective. The only problem is that the effect lasts three and a half weeks. During the week before the next shot, his migraine headaches become severe and frequent. Sumatriptan helps but his disability as measured by the MIDAS scale is in the moderate range. He is a high-level executive in a large corporation and needs better control of his migraines. He had tried the other two monoclonal antibodies for migraines – Aimovig and Ajovy – and they were less effective.

Fortunately, there is a good solution to his problem. I advised him to take Emgality injections every three and a half weeks. This is a higher frequency than what is recommended by the FDA and some doctors and patients may have concerns about the safety. The one-month interval is based on averages derived from large studies. People, however, are not average. Some metabolize drugs faster or need a higher or a lower dose of a drug. Another reassuring fact about Emgality is that it is approved at a much higher dose for cluster headaches. For migraine, we give a 240 mg loading dose and then, 120 mg monthly. Patients with cluster headaches get monthly injections of 300 mg.

I have patients who have the same problem of the short duration of effect with Aimovig and Ajovy as well.

A major obstacle to the more frequent use of these drugs is the fact that insurance companies will only pay for 12 shots a year. These drugs cost about $600 to $700 a dose, so the cost is a major factor for many people. The way I get around it is by providing patients with free samples. Because we have three similar competing drugs, we get samples of all three. If you are having a similar problem, ask your doctor for a free sample. Some academic centers and large hospitals do not allow doctors to receive samples but most doctors in private practice can get them.

Headache after COVID vaccination

By: Dr. Mauskop

04-04-2022

Chronic migraine, Migraine, Science of Migraine

I recently saw a 32-year-old woman who never suffered from headaches until a year ago when she was given an injection of a COVID vaccine (J&J). Her headache started the day after vaccination and it has persisted unabated. Besides severe daily headaches, she developed profound fatigue, muscle aches, and brain fog, making her unable to work. Her headaches had all the features of chronic migraines and I recommended trying Botox injections along with a migraine medication that she has not yet tried.

I’ve seen a few dozen patients who developed less devastating headaches or whose preexisting migraines worsened after vaccination. Some developed a headache after the first or second shot and a few had it only after the booster. I am not suggesting that people should avoid the COVID vaccine. I’ve had three shots myself. I am writing about this because of a study just published by European researchers in the Journal of Headache and Pain – “Headache onset after vaccination against SARS-CoV-2: a systematic literature review and meta-analysis.”

They examined the results of 84 scientific reports that included 1.57 million participants, 94% of whom received Pfizer or Oxford-AstraZeneca vaccines. They discovered that vaccines were associated with a doubling of the risk of developing a headache within 7 days from the injection compared to people who received a placebo injection. They did not find a difference between the two different vaccine types. Some people developed a headache within the first 24 hours. In approximately one-third of the cases, headache had migraine-like features with pulsating quality, phonophobia, and photophobia. In 40 to 60% the headache was aggravated by physical activity, which is another migraine feature.

The majority of patients used some medication to treat their headaches. People reported that the most effective drug was aspirin, although the details about various treatments were not provided. We do know that in Europe doctors are much less likely to prescribe medications, including triptans. It is likely that early and aggressive treatment can prevent these headaches from becoming chronic and disabling.

Migraine World Summit is on again and it offers a wealth of information

By: Dr. Mauskop

24-02-2022

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

I am happy to announce that you can attend the Migraine World Summit free of charge. It is back on March 16-24, 2022 for its 7th annual virtual event. As one of the former presenters, I can tell you that you may greatly benefit from learning about the latest research on how to best manage migraine.

Migraine World Summit is a 9-day event where 32 of the world’s leading experts on migraine and headache research are interviewed on topics voted on by real patients. These interviews are online and can be accessed from anywhere in the world, but are only available free during the 9-day event.

Get your ticket today at MigraineWorldSummit.com