Botox 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.
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Cluster 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 MoreWomen with menstrual migraines who also have chronic migraines can be successfully treated with hormonal therapy, according to a study by Drs. Calhoun and Ford published in journal Headache. Surprisingly, controlling menstrual migraines led to improvement in chronic migraines as well. Chronic migraine is defined as a headache with migraine features that occurs on more than 15 days each month and it affects a staggering 4%-5% of the population. Hormonal therapy usually consists of taking an oral contraceptive continuously for many months, thus eliminating menstrual periods and often headaches and PMS symptoms. Oral contraceptives should not be taken by patients who have visual aura – visual disturbance that usually lasts 30 minutes and precedes the headache.
Read MoreTreating migraines in adolescents presents some unique challenges. Besides difficulties, such as getting them to bed before midnight and getting them to improve their diets, we face the problem of not having any FDA-approved drugs to treat migraine attacks. And it is not for lack of trying on the part of makers of triptans, which are drugs that work miracles for many adult headache sufferers. The problem has been proving to the FDA that these drugs work in kids. Because children tend to have shorter attacks, by the time we try to assess the efficacy of a particular drug two and four hours after the pill is taken, the headache is gone even if the pill was a placebo. Many studies have shown that the triptans are safe and effective (as was observed in kids who have longer duration of attacks). Many, but far from all headache specialists use triptans, such as Imitrex and Maxalt in adolescents. A study just published in Headache proved that Axert, another drug in the triptan family and that was tested in 866 children, is effective in children 15 to 17 years of age. The bottom line is that triptans can be safely used in kids who suffer from severe migraine headaches. I am often asked by other physicians, what is the youngest age I would prescribe a triptan? Because of a shortage of pediatric neurologists I feel compelled to see children as young as 10 and this is the youngest age at which I will prescribe triptans.
Read MoreMenstrual migraines are at times very difficult to treat. Triptans, such as Maxalt, Imitrex and other are usually very effective, but in some patients do not provide sufficient relief. Corticosteroid drugs, such as prednisone and dexamethasone can help some patients. Marcelo Bigal and his colleagues compared treatment of menstrual migraines with Maxalt alone, dexamethasone alone, and combination of the two. Maxalt was much better than dexamethasone, providing sustained 24-hour relief in 63% of patients vs 33%, but the combination was better than Maxalt alone, giving relief to 82% of women. We would always try Maxalt or a similar drug alone, but if one drug is insufficient a combination with dexamethasone should be tried. Corticosteroids should not be used for more than a few days a month because frequent and prolonged use can lead to serious side effects.
Read MoreTreximet, a new migraine treatment was approved today by the FDA. Treximet is a combination of two old drugs – sumatriptan (Imitrex), 85 mg and naproxen (Aleve), 500 mg. The combination is more effective than Imitrex alone because naproxen provides additional relief through its anti-inflammatory and pain relieving effects. Imitrex is losing its patent protection and is going to be available as a generic drug in 2009. The maker of Treximet, GlaxoSmithKline is hoping to switch most of the patients currently taking Imitrex to Treximet before patent expiration, in order to reduce its losses to generic competition. However, it is likely that insurance companies will force physicians to prescribe generic Imitrex and generic naproxen rather than pay for Treximet. GSK argues that the combination drug, just like Imitrex are fast-dissolving and therefore faster acting drugs than the generic naproxen is and the generic Imitrex is going to be.
Read MoreBotulinum toxin injections relieve tension headaches, according to a study just published in the European Journal of Neurology . Most of the previous studies had been conducted in patients with migraines or chronic migraines (more than 15 days of headaches a month). There is much less evidence that Botox also helps tension headaches. Our experience at the NYHC treating patients with tension headaches with Botox injections has been also very positive. In this European study doctors used Dysport – a version of botulinum toxin type A that is not available in the US. However, Dysport is very similar to Botox. On the other hand, Myobloc, which is botulinum toxin type B, is a very different version of botulinum toxin and in several aspects is inferior to Botox.
Read MoreMigraine and cluster headaches that do not respond to the usual treatments, may improve with injections of histamine. Dr. Seymour Diamond of the Diamond Headache Clinic in Chicago has pioneered the use of histamine in cluster headaches. We have found that in cluster headache patients for whom nothing else works histamine often provides excellent relief. A recent study published in the journal European Neurology suggests that histamine injections may also help migraine patients.
Read MoreA new drug may be better for the prevention of migraines than the old ones in the same category. A study just published in Headache suggests that nebivolol, a beta-blocker just approved in the US for the treatment of high blood pressure may be as effective as old beta-blockers, but with significantly fewer side effects. Beta-blockers, such as propranolol (Inderal), timolol (Blocadren) metoprolol (Toprol), atenolol (Tenormin) and nadolol (Corgard) have been used for the prevention of migraines for many years. However, many patients could not tolerate them because of side effects, mostly fatigue, slow heart beat and low blood pressure. Nebivolol appears to cause these side effects 50% less often, while preventing migraine attacks with equal efficacy.
Read MoreAnti-epilepsy drugs such as Neurontin (gabapentin), Topamax (topiramate) and Depakote (divalproex) have been proven to prevent migraine headaches. Each drug works for about half of the patients who try it. The other half either does not get any benefits or develops side effects. This does not seem to be that effective, but these drugs do beat placebo in blinded trials. We also know that not all anti-epilepsy drugs work for headaches. Tegretol (carbamazepine) was never shown to help and a study just published in Neurology confirms our impression that its cousin, Trileptal (oxcarbazepine) does not work either. We do occasionally see good results with two other epilepsy drugs, Keppra (levetiracetam) or Lamictal (lamotrigine), but large clinical trials proving their efficacy are lacking.
Read MoreMemantine is an old medication which has been available in Europe for over 30 years, but was only recently introduced in this country for the treatment of Alzheimer’s disease. Memantine blocks a specific receptor in the brain cells. Activation of this so called NMDA receptor is responsible for many negative effects, including pain and nerve cell damage. As soon as the drug was introduced in the US pain and headache specialists tried using it for pain, but probably because it is a weak blocker of the NMDA receptor our experience with this drug has not been very impressive. However, in the recent issue of journal Headache Greek doctors report that one patient with chronic migraines obtained complete relief due to memantine. One case report clearly does not prove that memantine is going to work for any significant percentage of patients. However, this drug has relatively few side effects and if the usual treatments fail it may be worth trying.
Read MoreTopamax is a popular drug for the prevention of migraine headaches. IT works for about half of the patients who try it. The main problem that makes people stop taking the drug is cognitive side effects. Patients tell us that they feel “stupid” on this drug. An article just published in the European Journal of Neurology pinpoints the main cognitive problem, which turns out to be word fluency. This means having trouble coming up with the right word.
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