Medications used for the preventive treatment of migraine headaches can cause weight loss, but more often cause weight gain. An interesting study by Dr. Bigal and his colleagues, just published in Cephalalgia looked at this effect of drugs in 331 patients. They found that 16% of them gained weight (5% or more of their baseline weight) and 17% lost weight. The various treatments given to these patients were equally effective in both groups. However, not surprisingly, those who gained weight had elevation of their cholesterol, blood glucose, blood pressure and pulse. Patients who have migraine headaches with aura (about 15-20% of migraine sufferers) already have an increased risk of strokes, so adding additional risk factors for both strokes and heart attacks should be especially avoided in this group. The only preventive migraine drug which consistently lowers weight in many patients is topiramate (Topamax). This drug is now available in a generic form, making it much less expensive. While topiramate does lower weight and helps prevent migraine headaches only half of the patients stay on it. For the other half it causes unpleasant side effects (memory impairment and other) or it does not work.
Read MoreTrigeminal neuralgia is an extremely painful condition which causes severe electric shock-like pain in one or more branches of the trigeminal nerve. The 3 branches are mandibular, in the lower jaw, maxillary, in the upper jaw, and ophthalmic in the upper face. It is more common in the elderly and is caused by compression of the trigeminal nerve by a hardened blood vessel inside the skull, near the brainstem. Treatment consists of trials of different medications, which work for most patients, but a small percentage require a partial destruction of the nerve (with radiofrequency heat) or surgery. Surgery consists of opening the skull and placing Teflon insulation between the nerve and the blood vessel. Medications that are used for trigeminal neuralgia inlcude epilepsy drugs, such as carbamazepine (Tegretol), oxcarbazepine (Trileptal), phenytoin (Dilantin), and a muscle relaxant, baclofen (Lioresal). A recent report suggests that a newer epilepsy drug, pregabalin (Lyrica) is also effective. However, carbamazepine, phenytoin, and baclofen are available in a generic form, which makes them much less expensive than the other, branded products.
Read MoreIn addition to an injection, tablet and a nasal spray, sumatriptan is being tested in two other formulations. No, it is not an inhaled form, which I just posted in my previous blog (dihydroergotamine inhaler), but through a skin patch and by a “lingual spray”, that is a spray into the mouth. The skin patch may work fast and will deliver medicine through the skin, bypassing the stomach, which would be very useful for people who get very nauseous and have difficulty swallowing medications. However, it is quite a large patch and will probably cost significantly more than a tablet, particularly in the generic form. The second new formulation, a spray into the mouth, appears to partially absorb in the mouth and partially in the stomach, making it also work faster, although so far it looks to be only as effective as a 50 mg tablet. The usual dose is 100 mg. Also, hopefully the company that is developing this product has been able to mask the taste of sumatriptan. Patients who have tried the nasal spray often complain of a very unpleasant taste, which can make nausea worse.
Read MoreTrials of an inhaled version of an old migraine drug show surprisingly good results. The drug is dihydroergotamine and in injectable from is considered to be one of the strongest migraine medications. It is often used intravenously to treat severe migraines that do not respond to other therapies and for medication overuse headaches. It can be also injected into the muscle, under the skin or sprayed into the nose. The main problem with this drug is that it often makes nausea worse or even causes severe nausea in patient who do not have it. What is surprising about the new product being developed by MAP Pharmaceuticals (to be called Levadex if and when FDA approves it) is not that is is very effective, but that it causes significantly less nausea than the same drug in an injectable form. Another advantage is that inhaling the medicine into the lungs results in a very quick delivery of the drug into the circulation – as quick as an injection but without a needle. A similar product, Ergotamine Medihaler was available until about 15 years ago, but was withdrawn because of manufacturing difficulties and limited demand. The demand for this new product will also be limited because it will be more expensive than a tablet of any migriane drug, it will be more bulky to carry around, and will be mostly utilized by patients who cannot take oral medications due to nausea or by those who need very quick onset of action to abort an attack.
Read MoreImitrex and Topamax are two migraine medications that recently lost their patent protection and became available in a generic form, under the names of sumatriptan and topiramate. Many patients are concerned about the quality of generic products. A recent study published in Neurology looked at 948 patients with epilepsy who were treated with generic Topamax (it is approved for the treatment of both migraines and epilepsy). Compared to patients who used the branded Topamax, those on generic substitutions needed to have more of other medications, were admitted to the hospital more frequently and stayed in the hospital longer. The risk of head injury or fracture (presumably due to seizures) was almost three times higher after the switch to a generic drug.
Clearly, migraine patients do not run the same risk as epilepsy patients of having a seizure or being admitted to the hospital, however a small number of patients can have worsening of their migraines. The main reason is the legally permitted variation in the amount of medicine in each tablet. Taking a higher dose of the generic drug can help.
The same applies to Imitrex – a small number of patients will find that the generic sumatriptan is slightly less effective. The only, albeit significant, advantage of the generic drugs is cost savings. At this point we have only one generic substitution for Imitrex and the price difference is only 20%, but in a few months more generics will appear and the price should drop significantly, which is a very welcome development for patients with frequent migraines.
Read MoreOccipital nerve stimulation appears to be a promising new treatment for migraine and cluster headaches. Phase II trials performed by Medtronics, the manufacturer of one type of stimulator, have been positive. This stimulator requires implantation of a stimulator wire next to the occipital nerves and a separate incision to implant a stimulator device with a battery in the upper chest. A recent report suggests that the same effect can be achieved by implanting a small self-contained device without the need for wires, large battery, or a separate incision. This “Bion Microstimulator” has not been subjected to any extensive studies similar to ones performed by Medtronics, but the preliminary data looks promising.
Read MoreDr. Rami Burstein of Harvard University and his colleagues discovered the way to predict who is going to respond to Botox injections. Patients who have pain that is constricting, crushing, or “imploding” with pressure going from outside in and those with pain in the eye respond much better than those whose pain is “exploding” or with a sensation of pressure building up from inside the head. This was true for patients with episodic, as well as chronic migraine headaches. About 83% of non-responders had “exploding” headaches and 84 of responders had “imploding” headaches. Fortunately, many more patients suffer from imploding headaches or headaches with pain in the eye than with “exploding”headaches.
Read MoreCluster headaches, which arguably cause the worst pain of any headache, are not likely to be cured by trigger point injections, according to a group of Spanish doctors. They treated 12 patients with trigger point injections and some of the patients reported some relief, but they all needed medications as well. This is a small study without placebo control, which means that no conclusions can be made about usefulness of this treatment. We do have better evidence that occipital nerve blocks can be helpful in aborting cluster headaches. This is a procedure similar to trigger point injections, but it involves injection not only of a local anesthetic, but also a long-acting steroid into an area of the occipital nerve on the side of the headaches. It is a simple and safe procedure and it should be tried in most patients, particularly those who in addition to pain around the eye have pain or tenderness in the back of the head or upper neck.
Read MoreTreatment of menstrual migraines often is more difficult than of non-menstrual attacks. A double-blind study by Marcelo Bigal and his collaborators just published in Headache shows that a combination of 10 mg of rizatriptan (Maxalt) and 4 mg of a steroid medication, dexamethasone (Decadron) is more effective than either drug alone. Both drugs are effective in treating many refractory migraine attacks (although I usually use 8 mg of dexamethasone), this is the first trial of two drugs together. While the results are not very surprising, the study may lead to wider acceptance of combination therapy and better relief for many women. While in the past the emphasis was placed on finding a single drug to treat a disease, in recent years combination therapy has become a standard approach in many conditions. Treximet, a combination of sumatriptan (Imitrex) and naproxen (Aleve) was also shown to be better than either of the two ingredients alone.
Read MoreRefractory migraines may respond to occipital nerve stimulation, according to Dr. Joel Saper who led a multicenter trial of this treatment. An electrode was surgically implanted in the back of the head, where the occipital nerve is located, and a pacemaker-size device was implanted under the skin. The trial looked at 110 patients who had more than 15 days with migraines each month and who did not respond to a variety of medications. 66 patients completed the diary information for three months following the start of treatment. The results were encouraging – 39% of patients improved, compared with 6% in the control group. None of the patients had any adverse events.
Read MoreBotox is effective for chronic migraines, according to a statement released by Allergan, maker of Botox. The company reported that a large multi-center trial (the New York Headache Center was one of the trial sites) yielded positive results. This report did not surprise us or our colleagues who routinely use Botox in treating patients with chronic migraines. The excitement we feel is due to the fact that many of our colleagues have been skeptical about the efficacy of Botox. Much more importantly, we hope that this definitive study will compel insurance companies to pay for this treatment.
Read MoreCluster headaches cause the worst pain imaginable, leading some patients to thoughts of suicide. They occur in about 0.1% of the population, while migraine headaches afflict 12%, which may explain why so much less research has been conducted on cluster than on migraine headaches. Injectable sumatriptan (Imitrex) is the only drug approved by the FDA for cluster headaches. We do use many other medications “off-label” for both acute and prophylactic treatment, but none have been subjected to rigorous research. That is none, until recently – zolmitriptan nasal spray (Zomig NS) has been shown to be effective in relieving cluster headaches within 30 minutes. While the dose of Zomig NS for migraines is 5 mg, in this latest trial both 5 and 10 mg dose was studied. The 10 mg dose was better than 5 mg dose in patients with episodic cluster headaches (74% vs 52%), but these two doses were equally effective in patients with chronic cluster headaches (41% vs 42%). The advantage of Zomig NS over Imitrex injection is that it is easier to use and does not involve a painful injection, while the advantage of Imitrex is that it works faster. Zomig NS is now approved for acute treatment of cluster headaches in Germany, Netherlands and Denmark.
Read More
Recent Comments