New treatments | Headache NewsBlog

Suzetrigine: A Promising New Treatment for Pain

By: Dr. Mauskop

30-01-2025

Brain disorders, Chronic migraine, Cluster headaches, Headache medications, Headaches, Migraine, New treatments, Pain, Pain Research

FDA has approved suzetrigine (Journavx) for the treatment of moderate to severe acute pain. The drug was found to be as effective as Vicodin (hydrocodone with acetaminophen) after surgery to remove a bunion and after a “tummy tuck”.

Suzetrigine is a selective NaV1.8 inhibitor, targeting a key sodium channel involved in pain signaling. The NaV1.8 channel is crucial in transmitting nerve pain signals to the brain. However, the drug does not enter the brain and works only on the nerves outside the brain and in the body.

Unlike traditional pain medications such as opioids, suzetrigine provides effective pain relief without addiction risk or severe systemic side effects. Early clinical trials suggest it may be beneficial for conditions like neuropathic pain, post-surgical pain, and chronic pain syndromes. Hopefully, it will also prove effective in the treatment of migraines and other types of headaches.

In clinical trials, about 37% of patients experienced adverse events, though most were mild. These included itching, rash, constipation, and muscle spasms.

As a non-opioid option, suzetrigine provides clinicians with an additional tool for acute pain management. The medication is expected to become available in the second quarter of 2025. The expected cost is about $15 a pill.

A new device to treat chronic migraines

By: Dr. Mauskop

14-01-2025

Alternative Therapies, Chronic migraine, Headaches, Migraine, neurostimulation, New treatments

The Chordate System, using a technique called Kinetic Oscillation Stimulation (K.O.S), has shown promising results in reducing monthly headache days for people with chronic migraines, according to a study just published by European neurologists in the journal Neurology.

The treatment involves gentle stimulation inside the nasal cavity using a specialized catheter that delivers precise pressure and vibrations. Each session lasts 10 minutes per nostril and is administered weekly. The device works by potentially modulating the trigeminal nerve pathways involved in migraine attacks.

Study design: The study was randomized, double-blind, and sham-controlled.

Participants: Patients with chronic migraine (defined as headaches occurring on 15 or more days per month, with at least 8 of those being migraine days). The active treatment was given to 67 patients and the sham to 65.

Treatment: Weekly K.O.S sessions for six weeks.

Primary Endpoint: Change in monthly headache days with moderate to severe intensity (MHDs) from baseline to the performance assessment period (days 14–42).

Secondary Endpoints: These included changes in monthly migraine days (MMDs), reductions in headache severity, use of abortive medications, and improvements in quality of life.

Key Findings

The results demonstrated that K.O.S provided significant benefits for patients with chronic migraine:

Reduction in Monthly Headache Days (MHDs):

Active treatment resulted in a reduction of 3.5 MHDs during the assessment period, compared to a 1.2-day reduction with sham treatment.

This improvement persisted into the follow-up period, with a 2.7-day reduction in MHDs compared to sham.

Reduction in Monthly Migraine Days (MMDs):

Patients receiving K.O.S experienced a 2.4-day reduction in MMDs during the assessment period with effects lasting into follow-up (2.9 days).

Responder Rates:

A significant proportion of participants achieved a 30% or 50% reduction in moderate-to-severe headache days, demonstrating the clinical relevance of K.O.S.

Safety Profile:

Adverse events were mild and similar between the active and sham groups, with nasopharyngitis, dizziness, and minor nosebleeds being the most common. Importantly, no treatment-related serious adverse events were observed.

This non-drug approach offers a new option for people suffering from chronic migraines, especially those concerned about medication side effects. The treatment’s effectiveness is comparable to current standard medications while offering a non-pharmaceutical alternative.

The Chordate System (Ozilia) is not currently available in the United States, as it has not yet received FDA approval. However, the company, Chordate Medical, is actively working toward getting it approved.

We do have several FDA-approved devices to treat migraines. The most effective, practical, and affordable are Cefaly and Nerivio. Relivion, Savi Dual, and gammaCore are less so.

Can Magnetic Brain Stimulation (rTMS) Prevent Pain?

By: Dr. Mauskop

02-12-2024

Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Headaches in children, Migraine, Migraine in pregnancy, neurostimulation, New treatments, Pain, Pain Research, Science of Migraine, TMJ

Modern technology may help manage or even prevent pain before it becomes chronic. A recent study exploring the effects of repetitive transcranial magnetic stimulation (rTMS) on pain sensitivity offers some intriguing insights.

What is rTMS?

rTMS is a non-invasive method of brain stimulation. It involves sending magnetic pulses to specific areas of the brain through a coil placed on the scalp. This technique has been used to treat conditions like depression and chronic pain, but researchers are now looking at its potential to prevent pain. We used rTMS at the New York Headache Center to treat chronic migraine, other pain and neurological conditions that do not respond to usual treatment.

In a controlled experiment, researchers led by Nahian Chowdhury examined the role of rTMS in reducing future pain in healthy volunteers. The results were published in the latest issue of Pain, a journal of the International Association for the Study of Pain.

The subjects were divided into two groups:

Active rTMS Group: Received high-frequency rTMS to the area of the brain responsible for hand movements.

Sham rTMS Group: Received a fake treatment for comparison.

Both groups were then given an injection of nerve growth factor (NGF) into their jaw muscles, which causes prolonged pain similar to temporomandibular disorders (TMD), a condition causing jaw pain and dysfunction.

Results:

Pain Reduction: Participants who received active rTMS reported significantly less pain when chewing or yawning than the sham group. This effect was more pronounced in the early stages after the injection but persisted for days and weeks.

Brain Activity: The study found an increase in what’s known as peak alpha frequency (PAF) after rTMS, which is linked to lower pain sensitivity.

What Does This Mean for Pain Management?

Preventive Potential: This research suggests that rTMS could be used prophylactically to reduce pain sensitivity when pain is expected, like before surgery.

Future Directions: While promising, this study opens the door to further research into how rTMS can be optimized for pain control, potentially exploring different frequencies, duration, and areas of stimulation.

Pre-Surgery: rTMS might be used to reduce postoperative pain, potentially preventing the transition to chronic pain.

Chronic Pain Management: For those already dealing with chronic pain, understanding how brain activity changes with rTMS could lead to more effective treatments.

Conclusion

While we are still in the early stages, this study of rTMS offers hope for pain sufferers. It suggests a future where we might not only treat pain more effectively but also prevent it from becoming a long-term problem. This could revolutionize our approach to pain management, making it less about reducing and enduring pain and more about preventing it from taking root in the first place.

A new textbook on headaches and facial pain.

By: Dr. Mauskop

21-11-2024

Alternative Therapies, Blocks, Botox, Brain disorders, Chronic migraine, Cluster headaches, Head trauma, Headache medications, Headaches, Headaches in children, injections, Migraine, Migraine in pregnancy, neurostimulation, New treatments, Trigeminal and other neuralgias

It’s an honor to have contributed, alongside Andrew Blumenfeld and Sait Ashina, a chapter on Botox injections to the upcoming textbook Headache and Facial Pain Medicine. Edited by Sait Ashina of Harvard Medical School and published by McGraw Hill, the book is set for release in 2025 but is already available on Amazon.

The book includes chapters on Primary Headaches, Secondary Headaches, Facial Pain and Cranial Neuralgias, Special Treatments and Procedures, Special Populations, and Special Topics. It is an excellent textbook for health care providers.

New Daily Persistent Headache may respond to TMS

By: Dr. Mauskop

06-10-2024

Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Headaches in children, Migraine, Migraine in pregnancy, neurostimulation, New treatments, Pain

Researchers at a hospital in Northern India reported good results in treating New Daily Persistent Headache (NDPH) with repetitive transcranial magnetic stimulation (rTMS).

NDPH is a type of headache that begins suddenly and persists daily without specific features, distinct MRI presentation, or blood test abnormalities. It can present similarly to chronic migraines or chronic tension-type headaches. While published reports suggest NDPH is difficult to treat, this is often not the case. However, patients who do not respond to initial standard treatments may become discouraged.

The Indian researchers conducted a pilot study with 50 NDPH patients who received 10 Hz rTMS sessions on the left prefrontal cortex of the brain for three consecutive days. They found that after 4 weeks:

70% of patients had at least a 50% reduction in headache severity
Patients gained an average of 11 headache-free days per month
76% had significant improvements in headache-related disability
Depression and anxiety scores also improved significantly

The treatment was well-tolerated, with only minor side effects in a few patients. The benefits seemed especially pronounced in patients who had NDPH that resembled chronic migraine.

I never give the diagnosis of NDPH, but diagnose it as a condition it most resembles and treat the person with a wide variety of available options. Many respond. For those who do not, we offer rTMS, a procedure that uses magnetic fields to stimulate nerve cells in the brain. An electromagnetic coil device is placed against the scalp near the forehead. The coil painlessly delivers a magnetic pulse that stimulates the brain with the goal of reducing headache symptoms. The FDA has approved it for the treatment of depression, anxiety, and OCD. We use it for various neurological conditions, including headaches that do not respond to standard therapies. To treat migraines and other types of pain, we usually stimulate not only the left prefrontal cortex, as was done in this study, but also two additional sites that have been reported to help with pain and migraines. These additional sites are either the motor cortex or the occipital cortex, on both sides.

Sometimes, we obtain a functional magnetic resonance imaging (fMRI) scan to better target rTMS. fMRI is a research procedure that is not available commercially (and is not covered by insurance).

A novel migraine drug shows promise

By: Dr. Mauskop

08-09-2024

Alternative Therapies, Chronic migraine, Headache medications, Headaches, injections, Migraine, New treatments

Two sets of “designer drugs” have been developed based on our understanding of the neurobiology of migraines. The first, sumatriptan (Imitrex), introduced in 1992, was the pioneer in a class of seven triptan drugs, all targeting serotonin mechanisms. Erenumab (Aimovig), which targets the CGRP (calcitonin gene-related peptide) mechanism, was approved by the FDA in 2018. This class now includes four injectable, three oral, and one nasal drug. Additionally, many older drugs, although not specifically developed for migraine treatment, have proven effective for some patients. Despite these numerous options, a significant minority of patients do not respond to any of these treatments.

This is why the development of drugs targeting different parts of the migraine cascade is so promising. Danish neurologists, led by Dr. Mesoud Ashina, have published results from a phase 2 double-blind study of a new drug that blocks PACAP (pituitary adenylate cyclase-activating peptide).

In this study, patients were divided into two groups, receiving an infusion of a placebo or two different doses of the active drug, currently known as Lu AG09222, developed by the Danish company Lundbeck. In the final analysis, the reduction in migraine days was compared between 94 patients who received a placebo and 97 patients who received the higher dose of the active drug. The higher dose significantly reduced the number of migraine days in the month following the infusion (6.2 vs. 4.2 days reduction). The side effects reported were mild and infrequent.

Phase 2 studies are relatively small and short in duration. The FDA typically requires two large parallel studies involving a total of 1,000 or more patients before considering approval. Therefore, even if Lu AG09222 is found to be safe and effective, it may not receive approval for another 2-3 years.

What can you do about long COVID

By: Dr. Mauskop

26-08-2024

Alternative Therapies, Brain disorders, Chronic migraine, neurostimulation, New treatments

Long COVID, also known as post-COVID conditions, can present with a wide range of symptoms that persist for weeks or months after the initial COVID-19 infection. The most common symptoms of long COVID include:

Neurological Symptoms

Headaches
Difficulty thinking or concentrating, often referred to as “brain fog”
Memory problems
Changes in smell or taste

Psychological Symptoms

Depression or anxiety
Mood changes

Other Symptoms

Fatigue or tiredness that interferes with daily life
Shortness of breath or difficulty breathing
Cough
Chest pain or heart palpitations
Sleep problems
Dizziness when standing up (orthostatic hypotension)
Joint or muscle pain
Fever
Stomach pain or other gastrointestinal issues
Changes in menstrual cycles

There is evidence of persistent inflammation in people with long COVID. This inflammation of blood vessels, brain tissues, and other organs is likely the cause of all of the above symptoms.

Receiving a COVID vaccination may prolong the symptoms of long-term COVID-19 in people who have already contracted COVID and now suffer from long COVID. However, vaccines seem to reduce the risk of severe COVID and long COVID.

Unfortunately, we do not have any proven therapies for long COVID. However, it is very important to make sure that nutritional deficiencies do not contribute to long COVID symptoms. I often find a deficiency of vitamin B12 and other B vitamins, vitamin D, magnesium, CoQ10, omega-3 fatty acids, zinc, and others. I recommend looking at your test results yourself since doctors may glance at the report and tell you everything is fine if nothing is flagged. The normal ranges for vitamins are too wide, and if you are at the bottom of the normal range, you are probably deficient. For example, vitamin B12 levels are considered normal between 200 and 1,200. Most neurologists will tell you that your level should be above 500. The same applies to RBC magnesium level – normal is 4.0 to 6.4, but you need to be above 5. Vitamin D should be well above 40, while 30 is still considered normal.

Another supplement I often recommend is NAC. A small study by Yale neurologists showed that 600 mg of NAC improved working memory, concentration, and executive functions. NAC helps the body produce glutathione, an important antioxidant. We sometimes give glutathione infusions along with other vitamins.

Supplements that reduce inflammation include ginger and turmeric extracts.

For brain fog and other neurological symptoms, we have had some success with transcranial magnetic stimulation (TMS). Other neurostimulation methods, such as tDCS, are also worth trying.

Some patients benefit from intravenous infusion of immune globulin, which is approved for some types of neuropathies.

Low-dose naltrexone (LDN) may also help, but no studies prove this.

Probiotics can help people with gastrointestinal symptoms.

Stimulants can be tried to treat fatigue and brain fog. They can also help with depression.

For headaches, we often give Botox injections.

Depression can be treated with antidepressants or TMS.

Some people respond well to physical therapy, acupuncture, herbs, meditation, cognitive-behavioral therapy, and other mind-body techniques.

Focused ultrasound to specific brain regions relieves pain

By: Dr. Mauskop

04-08-2024

Alternative Therapies, Brain disorders, Chronic migraine, neurostimulation, New treatments, Pain

The use of focused ultrasound to treat brain disorders was one of the topics discussed at the 2024 NYC Neuromodulation Conference in NYC.

Coincidentally, a study on this topic was published last month by Jan Kubanek and his colleagues in Pain, the journal of the International Association for the Study of Pain: “Noninvasive targeted modulation of pain circuits with focused ultrasonic waves”.

Researchers developed a technique that targets the anterior cingulate cortex, a deep brain region involved in processing pain. By using focused ultrasound, this region can be modulated without surgery. This breakthrough has the potential to revolutionize pain management.

Twenty patients with chronic pain participated in a randomized crossover trial. They received two 40-minute sessions of either active or sham stimulation and were monitored for one week. The results were remarkable:

60% of patients experienced a significant reduction in pain on day 1 and day 7 after active stimulation.
Sham stimulation only benefited 15% and 20% of patients, respectively.
Active stimulation reduced pain by 60.0% immediately after the intervention and by 43.0% and 33.0% on days 1 and 7.
Sham stimulation only reduced pain by 14.4%, 12.3%, and 6.6% on the same days.

The stimulation was well tolerated and the side effects were mild and resolved within 24 hours.

Since we have been using transcranial magnetic stimulation (TMS) to treat refractory migraines and other neurological conditions, it was good to read this part of the authors’ conclusion:

“The ultrasonic intervention is conceptually related to TMS applied to the motor cortex, which can provide improvements in chronic pain in certain groups of patients. The key difference is that ultrasonic waves can directly modulate the deep brain regions involved in chronic pain, including the anterior cingulate cortex. Transcranial magnetic stimulation is believed to modulate deep brain regions only indirectly, which may contribute to its variable response and the need for frequent re-administrations. Nonetheless, the effects of both modalities may be complementary, and their combined application may provide stronger effects than either approach alone.”

Abnormal functional connectivity in brains of patients with vestibular migraine

By: Dr. Mauskop

27-05-2024

Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine, Migraine in pregnancy, neurostimulation, New treatments, Pain, post-traumatic headache, Science of Migraine

Functional MRI (fMRI) studies have shown that people with migraines have altered functional connectivity and activation patterns in pain-processing brain regions like the insula, thalamus, somatosensory cortex, as well as visual cortex. Some patients also have changes in the default mode and salience networks involved in attention and stimulus processing.

A study published this month by Chinese researchers in the Journal of Headache and Pain reports on connectivity changes in people with vestibular migraines.

They found abnormal resting-state functional connectivity in brain regions involved in multi-sensory and autonomic processing as well as impaired ocular motor control, pain modulation, and emotional regulation.

Until now, there has been little practical application for fMRI findings. However, with the help of Omniscient Neurotechnology, we have just started using fMRI data to better target our treatment with transcranial magnetic stimulation (TMS). TMS applied to motor and visual cortices has been reported to help relieve migraine headaches. We have also found it effective in a significant proportion of patients who did not respond to various other treatments. We have not yet accumulated enough data to determine if fMRI-guided TMS treatment is superior to TMS administered over a predetermined set of targets.

The main obstacle to wider use of TMS in clinical practice is the cost. TMS is approved by the FDA and is covered by insurance for the treatment of anxiety and depression, but not migraines or pain. fMRI is an expensive research tool and is also not covered by insurance. Hopefully, the NIH and other research foundations will provide the funds needed to study this promising treatment.

Visit with the Nolan Williams’ TMS team at Stanford

By: Dr. Mauskop

24-04-2024

Alternative Therapies, Brain disorders, Chronic migraine, Head trauma, Headaches, Migraine, neurostimulation, New treatments, Pain, Pain Research, post-traumatic headache

Nolan Williams has been at the forefront of developing breakthrough TMS protocols for the treatment of depression and other psychiatric indications. It was very stimulating and informative to discuss techniques, protocols, indications, and research into TMS for various neurological and psychiatric indications with the members of Nolan Williams’ lab Greg Sahlem and Ika Kaloiani. Thank you for sharing your knowledge.

Pain relief from transcranial magnetic stimulation is possibly opioid-mediated

By: Dr. Mauskop

07-04-2024

Alternative Therapies, Brain disorders, Chronic migraine, Cluster headaches, Headaches, Headaches in children, Migraine, neurostimulation, New treatments, Pain, Pain Research, Science of Migraine

Repetitive transcranial magnetic stimulation (rTMS) is approved by the FDA for the treatment of depression and anxiety. We have been using it to treat migraine headaches and other neurological conditions that are not responsive to standard therapies. Improvement in headaches and pain may be at least in part due to improvement in depression. However, additional mechanisms play a role since we see patients who are not depressed but whose pain improves with rTMS.

A new study by Chinese and Australian researchers published in Pain suggests that opioid mechanisms (endorphins, encephalin, and other peptides) may underlie the mechanism of pain relief produced by rTMS.

This was a double-blind, placebo-controlled study. 45 healthy participants were randomized into 3 groups: one receiving rTMS over the primary motor cortex (M), dorsolateral prefrontal cortex (DLPFC), or sham stimulation. Experimental pain was induced by applying capsaicin (hot pepper extract) over the skin of the right hand followed by application of heat.

Participants received intravenous naloxone (an opioid receptor antagonist) or saline before the first rTMS session to block or allow opioid effects, respectively. After 90 minutes to allow naloxone metabolism, participants received a second rTMS session.

For the M1 group, naloxone abolished the analgesic effects of the first rTMS session compared to saline. Pain relief returned in the second session after naloxone was washed out of the body. For the DLPFC group, only the second prolonged rTMS session induced significant analgesia in the saline condition compared to naloxone. rTMS over M1 selectively increased plasma ?-endorphin levels, while rTMS over DLPFC increased encephalin levels.

The results suggest that opioid mechanisms mediate rTMS-induced analgesia. The specific opioid peptides and rTMS dosage requirements differ between M1 and DLPFC stimulation.

However, these results are far from definitive. The study was small and the study protocol was complicated (e.g. using a double dose of rTMS to DLPFC), which increases the likelihood of an error. Also, these results apply to conditions of acute pain. In patients with chronic pain and headaches, rTMS likely provides relief by improving network connectivity between different parts of the brain.

CGRP drugs in pregnancy

By: Dr. Mauskop

02-03-2024

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

A new report suggests that CGRP-blocking drugs (CGRP-A) are safe in pregnancy.

In the latest study, Swiss doctors examined the World Health Organization’s pharmacovigilance database and looked at reporting differences between CGRP drugs and triptans.

Triptans (drugs like sumatriptan or Imitrex and six others) were introduced over 30 years ago. We know from pregnancy registries, retrospective, and prospective observational studies that triptans are safe in pregnancy.

The WHO database had 467 safety reports of exposure to CGRP-A in pregnancy. Of these, 386 were reports of exposure to CGRP monoclonal antibodies (mAbs), 76 to gepants, and 5 to both. The authors found “…no signals of increased reporting with CGRP-A compared to triptans in relation to pregnancy”.

CGRP drugs represent a major breakthrough in treating migraine headaches. A large proportion of migraine sufferers are women of childbearing age. We always have to consider the effect of a drug on the developing fetus. Erenumab (Aimovig), the first drug in this category was introduced almost six years ago. This is a relatively short period to assess the safety of a drug in pregnant women and the current report is not a definitive proof of safety.

There might be a difference in safety between oral CGRP antagonists (gepants), which are small molecules and injectable mAbs, which are large molecules. Gepants have the advantage of being completely washed out of the body within a few days of stopping them. Monoclonal antibodies are injected every one or three months and can take a few months to completely leave the body. However, mAbs, being larger, cannot cross the placenta in the first trimester. So if a mAb is stopped at the beginning of pregnancy the exposure to the fetus will be small.

The gepants include ubrogepant (Ubrelvy), rimegepant (Nurtec), atogepant (Qulipta), and a nasal spray, zavegepant (Zavzpret). The monoclonal antibodies are erenumab, fremanezumab (Ajovy), galcanezumab (Emgality), and eptinezumab (Vyepti).