Results of a phase II study of a new headache medicine was published in journal Neurology. Merck and Co. is starting phase III trials of this drug, which works by blocking the release of a neurotransmitter CGRP. Previous migraine medicines, such as sumatriptan (Imitrex), rizatriptan (Maxalt), eletriptan (Relpax) and other in the triptan family worked on serotonin receptors. While the triptans are very safe they very rarely can constrict blood vessels in the heart and cause a heart attack. The new medicine, which is known as MK-0974 does not constrict blood vessels. In the published trial it was at least as effective as Merck’s older drug, Maxalt. If phase III studies go well we could see this medicine on the market in a couple of years.

The United States Food and Drug Administration (FDA) has approved a new formulation of Imitrex Injection that allows a convenient way for patients to take a 4mg dose using the Imitrex STATdose System®. Imitrex Injection is indicated for the acute treatment of migraines with and without aura in adults. The United States Food and Drug Administration (FDA) has approved a new formulation of Imitrex Injection that allows a convenient way for patients to take a 4mg dose using the Imitrex STATdose System®. Imitrex Injection is indicated for the acute treatment of migraines with and without aura in adults. We find that Imitrex injections are very underutilized, mostly because doctors don’t offer them as an option to their patients. Surprisingly, surveys indicate high acceptance of injections by patients. This should not be so surprising at all considering how disabling migraines can be. The ideal candidates for injectable Imitrex include patients who have severe nausea, those who wake up with a severe attack and need prompt relief, patients for whom oral triptans do not provide adequate relief and those with cluster headaches. We typically prescribe 6 mg injections and use 4 mg ones for patients who are very sensitive to drugs, have small weight or have side effects from 6 mg.

It is not clear how Botox relieves migraine headaches.

Oliver Dolly, an Irish researcher who devoted many years of his work to the study of botulinum toxin, has just published results of a new study which may help explain this question. Twelve years ago when I started using Botox for the treatment of headaches the only possible explanation for the way it worked was that it relaxed tight muscles. It is true that during a migraine attack muscles go into a contraction and many patients find some relief by massaging their temples, back of their head and neck. However, some people reported to me that injecting Botox relieved their headaches in the temples, forehead and back of the head, but not on the top of the head. I did not inject the top of the head because there are no muscles there. When I did inject those areas to my surprise pain on the top of the head improved as well. This has been also observed by many of my colleagues around the country. Dr. Dolly’s experiment showed that in addition to relaxing muscles, Botox prevents the release of CGRP (a chemical messenger – neurotransmitter) from nerve endings and stops painful messages from being transmitted along the nerves. It appears that relaxing muscles may be less important than stopping nerves from sending pain messages to the brain.

A study just published by Dr. Mathew and his colleagues in the journal Headache reports that patients with chronic migraine headaches responded to Botox better than patients with chronic tension headaches. Patients who had headaches predominantly on one side and those with scalp tenderness had a better response to Botox. Scalp muscle tenderness was also a predictor of response in chronic tension headaches. Overall, Botox was highly effective in patients with chronic migraine – 76%, (54 out of 71 patients) obtained relief. Of those 54 patients 37 or 69% had one-sided headaches. Having headaches on both sides does not preclude success with Botox – 17 patients with bilateral headaches also responded. This study confirms what I have observed in my 12 years of treating thousands of patients with Botox – it is a highly effective and safe treatment for frequent migraine headaches.

Prolapse or herniation of the upper cervical disc is known to cause not only neck pain but also so called cervicogenic headaches. Dr. Diener and his German colleagues reported (in journal Cephalalgia) on 50 patients who had prolapse of lower cervical disks and used as controls 50 patients with lumbar disk herniations. They found that 12 out of 50 patients with lower cervical disk herniations developed a headache and in 8 out of 12 headache stopped within a week following surgery. Only two of the patients with lumbar disk herniations developed a headache. Three months after surgery seven of 12 had no headaches and three were improved. It is not very surprising that these patients had headaches – neck muscles overlap all along the neck and form a supporting collar for the cervical spine. Muscle spasm in the lower neck that accompanies a herniated disk will often cause this spasm spread up the neck and cause a headache. Even patients with migraines at times develop a migraine attack from spasm of muscles in the neck or even shoulders. When treating these patients, both with migraines and cervicogenic with Botox injections are usually given not only into the muscles around the head, but also in the neck and shoulders. This makes Botox treatment significantly more effective.

Hemiplegic migraine can be safely treated with triptans (drugs like Imitrex, Maxalt and other).

This is the conclusion of a study published in the September issue of journal Cephalalgia. A group of Finnish doctors gave triptans to 76 patients who suffered from hereditary and non-hereditary forms of hemiplegic migraine – migraine that is accompanied by temporary paralysis of one side of the body. They found that triptans worked well and none of the patients had strokes or any other serious reactions. According to the FDA, triptans are not to be given to patients suffering from hemiplegic migraine because they potentially could cause a stroke. No strokes have ever been reported, but it was thought that constriction of blood vessels in the brain during hemiplegic migraine is responsible for the weakness and giving triptans could worsen this constriction and cause a stroke. In the past several years we have learned that weakness is caused by a disturbance of brain neurons rather than constriction of blood vessels. Many headache specialists use Imitrex and similar drugs in patients with hemiplegic migraine and several years ago Drs. Klapper and Mathew have already reported on their positive experience in a small group of patients.