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Allergan Announces Positive Results for Ubrogepant – an Oral CGRP Receptor Antagonist for the Acute Treatment of Migraine

By: Dr. Mauskop

21-03-2018

Chronic migraine, Headache medications, Migraine, New treatments

The first of the four CGRP monoclonal antibodies developed for the prevention of migraines is expected to be approved by the FDA in the next 2-3 months. The other three should be approved within a year. All four will be given by an injection (three subcutaneously and one, intravenously).

Most people prefer tablets to injections and two companies are developing three drugs with the same mechanism of action as the monoclonal antibodies (blocking CGRP), but in a tablet form. The original CGRP drug in a tablet form was developed by Merck and it was very effective for the prevention and acute treatment of migraines, but a few patients developed liver side effects. The side effects were not serious, just abnormal blood tests, which returned to normal once the drug was stopped, but nevertheless Merck stopped the development of telcagepant in 2009. This led pharma companies to shift to the development of monoclonal antibodies, which bypass the liver, but can be given only by injection.

Allergan and Biohaven are two companies that are developing oral CGRP drugs in the hope that they can achieve good efficacy without the side effects. Allergan just released the results of the first phase 3 study of ubrogepant. The study included 1327 U.S. adult patients who were given placebo, ubrogepant 50 mg or 100 mg. They treated a single migraine attack of moderate to severe headache intensity. Both doses were significantly better than placebo in achieving pain freedom at 2 hours after the initial dose. Sensitivity to light, noise, and nausea also significantly improved with the drug, but not placebo. The side effect profile of ubrogepant was similar to placebo without serious liver problems.

Results of the second phase 3 trial are expected in the first half of 2018. Allergan plans to file these results with the FDA in 2019, after which the FDA has a year to review the data and will hopefully approve the drug.

Breakthrough in the treatment of migraines

By: Dr. Mauskop

08-12-2017

Cluster headaches, injections, Migraine, New treatments

Two landmark studies on an entirely new type of treatment for migraines have been just published in the New England Journal of Medicine.

One of the reports describes a phase 3 trial (final phase that can lead to the FDA approval), which was conducted by Teva Pharmaceuticals using a monoclonal antibody, fremanezumab to treat patients with chronic migraine (patients with 15 or more headache days each month). The study involved 1,130 patients who were divided into three groups: one group received monthly injections (subcutaneously, i.e. under the skin) of the active medicine, another group was given an injection of the real medicine every 3 months and placebo injections monthly in between, and the third group received placebo injections every month. Patients in both groups that received real shots did much better than those given placebo. They had fewer days with headaches, used less of the abortive migraine medications, and had a lower impact of migraines on their lives. The effect of the drug lasted 3 months, which suggests that one injection every three months will be sufficient. We also hope that patients will be able to inject themselves and not have to come to doctors’ offices every month. The side effects were mostly related to the injection itself – pain, swelling, and bruising.

The second study conducted by Amgen and Novartis utilized a similar drug, erenumab (it will have the brand name of Aimovig when it becomes available in the middle of next year) to prevent episodic migraines, that is migraines that occur on fewer than 15 headache days each month. A total of 955 patients participated in this study and they were also divided into three groups: those receiving either 70 or 140 mg of medicine and a group receiving placebo. Injections were given monthly to prevent migraine attacks. Both doses of the drug resulted in significantly fewer migraine attacks and improvement in physical impairment and everyday activities. Side effects were mostly due to the injection site reactions, just like with fremanezumab.

Both fremanezumab and erenumab belong to the family of CGRP monoclonal antibodies, drugs that block a neurotransmitter CGRP which is released during a migraine attack. Two additional companies, Eli Lilly and Alder are developing similar drugs, galcanezumab and eptinezumab, which are also expected to be approved next year. Eli Lilly’s drug is also being tested for the prevention of episodic cluster headaches.

I first wrote about the CGRP drugs in a blog post in 2007, more than 10 years ago. At that point CGRP was the target of research for over 10 years, so in total, it will have taken 20 years to bring these new drugs to the market. It was even longer with triptans, such as sumatriptan (Imitrex) – it took 30 years since the discovery of the potential role of serotonin to the approval of sumatriptan. The drug development process takes not only decades of time, but also billions of dollars, which explains why new drugs are so expensive, at least in the first few years. After years of being on the market, prices of drugs tend to go down and now 90 tablets of sumatriptan can be bought for $70 at Costco, while similar branded triptan drugs used to cost $40 for a single tablet.

More on intravenous ketamine for migraines

By: Dr. Mauskop

05-11-2017

Alternative Therapies, Headache medications, Migraine, New treatments

Ketamine is a medicine that is sometimes given intravenously for anesthesia. It is a controlled drug because it can induce euphoria and is potentially addictive. In a previous post I mentioned several anecdotal reports about the beneifical effect of ketamine for a prolonged migraine aura, hemiplegic migraine and other types of headaches.

A presentation at the recent annual meeting of the American Society of Anesthesiologists described the results of ketamine infusion on severe migraines in patients admitted to the Thomas Jefferson University Hospital in Philadelphia from 2014 to 2016. 48 of the 61 patients (77%) responded to this treatment, meaning that their pain levels improved by at least 2 points on a 1 to 10 scale. On average, the infusion had to be given for 5 days. Side effects included sedation (51%), blurry vision (38%), nausea or vomiting (38%), hallucinations (28%), vivid dreams (13%), and low blood pressure (5%). The authors described the adverse effects as mild in nature and only 1 patient discontinued treatment. However, having hallucinations, drop in blood pressure or vomiting does no sound like mild side effects to me. On the other hand, these were patients whose migraine did not respond to other treatments and they needed to be hospitalized, so these side effects could in fact be acceptable if the treatment ultimately provides relief.

Review of patient records admitted to the same hospital between 2006 and 2014 showed the mean headache pain rating using a 0-10 pain scale dropped from 7 on admission to 4 on discharge. The majority (55 out of 77, or 71%) of patients responded by the same definition of an at least 2-point improvement in headache pain at discharge. Only a quarter of responders maintained this benefit at their follow-up office visit. The mean length of infusion was also 5 days. And again, most patients tolerated ketamine well with “very few serious side effects”.

Anecdotal evidence also exists for the use of ketamine infusions to treat depression. There are some outpatient clinics that offer ketamine infusions for chronic pain and depression and a few of my patients have gone there, but unfortunately with little success.

New research on cannabis for migraines

By: Dr. Mauskop

19-06-2017

Alternative Therapies, New treatments, Science of Migraine

Medical marijuana has been legalized in NY and more than 20 other states. It is approved in NY for several medical conditions, including pain and some of my patients with headaches (about one out of 3), arthritis, and other pains have found it to be very helpful. Some patients use it acutely (as a vaporizer or tincture) and report relief of pain, and/or nausea and for some it allows them to go to sleep and sleep off their migraines. Tablets of medical marijuana can prevent migraines if taken once or twice a day. Most people need products with a low THC/CBD ratio which does not cause euphoria or other cognitive effect.

Despite the requirement by states to have verified amounts of active ingredients, THC and CBD in the medical marijuana products, the efficacy and the side effects vary from manufacturer to manufacturer. This could be in part due to ingredients other than THC and CBD. Fortunately, many researchers are looking into the effect of pure ingredients and their mechanism of action.

Such a study was presented at the recent meeting of the American Headache Society by scientists from the Missouri State University led by Paul Durham. They developed a new animal model of migraine in rats and triggered a process in the rats’ brains that is similar to a migraine in humans. Administering cannabidiol (CBD) suppressed increased sensitivity in the trigeminal nerve and produced other positive effects, suggesting a possible mechanism by which CBD may relieve migraine and other facial pains. The next logical step would be to add small amounts of THC to see if it enhances the effect of CBD (so called entourage effect).

A new drug is approved for temporal arteritis, cause of headaches in those over 50

By: Dr. Mauskop

31-05-2017

Headache medications, Headaches, New treatments

Temporal arteritis occurs in one out of 5,000 people over 50. Women are 3-4 times more likely to be affected. It is not common below the age of 60 and becomes more prevalent with the advancing age. Temporal arteritis is also known as giant cell arteritis because it causes inflammation of arteries with giant cells seen under the microscope.

Headache is often the first symptom and it is typically localized to one temple, but it can involve other parts of the head and occur on both sides. If left undiagnosed and untreated temporal arteritis can cause a stroke and blindness, which can affect both eyes.

Besides headaches, temporal arteritis can cause neck and jaw pain, weakness, muscle aches, and a mild fever. The preliminary diagnosis is made by blood tests (ESR and CRP) and it is confirmed by a biopsy of the temporal artery. Polymyalgia rheumatica is a related rheumatological condition, which can occur alone or with temporal arteritis and it causes severe muscle pains.

Temporal arteritis (and polymyalgia rheumatica) are treated with steroid medications, such as prednisone. Although the initial dose is high, relatively small doses are usually effective for maintenance. Since the condition can last for years and long-term intake of prednisone can cause many potentially serious side effects it is very important to perform a temporal artery biopsy in most cases, rather than rely just on blood tests and clinical diagnosis.

Subcutaneous injection of Actemra (tocilizumab) was just approved by the FDA for the treatment of temporal arteritis. This drug has been available since 2010 for the treatment of rheumatoid and other forms of arthritis. Actemra was injected every two weeks for a year along with prednisone, but more patients were able to get off prednisone if they received Actemra rather than a placebo injection. Unfortunately Actemra also has potentially dangerous side effects, such as serious infections and it requires regular blood tests.

Because headache is one of the main symptoms of giant cell arteritis, the condition is often diagnosed by a neurologist or a primary care doctor. The treatment though is typically handled by a rheumatologist and they are already familiar with tocilizumab.

Guidelines for the use of medical marijuana

By: Dr. Mauskop

24-10-2016

Alternative Therapies, Headaches, Migraine, New treatments, Pain

Medical marijuana was legalized in New York in February of this year. Since then, I’ve prescribed it to over 30 patients and about a third of them have found it to be effective. We are planning an observational study to determine which of the three approved types (inhaled, sublingual, oral) and what ratio of active ingredients (THC/CBD) are preferred by migraine sufferers. Doctors who prescribe medical marijuana do have to take an online training course, but the course does not teach about the optimal use because no one has researched this question. There are also regulatory issues to deal with.

Several sets of guidelines have been published by various medical organizations addressing the proper use of medical marijuana, other than dosing and route of administration. Here are some of the recommendations with my comments:

“The doctor should adhere to current standards of practice and comply with state laws, rules and regulations, which may specify conditions for which a patient may quality.”
Migraine is not one of the conditions listed specifically, but it is often accompanied by neuropathic pain, which is listed.

“The doctor’s office should not be located at a marijuana dispensary or cultivation center. The doctor should not receive financial compensation from or hold a financial interest in marijuana-related businesses or be affiliated with them in any way.”
This one is easy for us.

“The physician should not use marijuana either medicinally or recreationally while actively engaged in the practice of medicine.”
I’ve never tried it.

“There should be an established doctor-patient relationship before the doctor considers the use of medical marijuana.”
I prescribe it only to our established patients.

“The doctor should do a physical exam and gather health history, including documentation of previous therapies used by the patient and information on any personal or family history of substance abuse, mental illness or psychotic disorders. The diagnosis should justify the consideration of medical marijuana.”
All of our patients undergo a thorough evaluation.

“The doctor should review other treatment options. The known benefits and risks of marijuana should be presented, along with the warning that, unlike with FDA-approved drugs, there is variability and lack of standardization in marijuana preparation.”
We use medical marijuana only after other non-drug and drug treatments fail.

“If the medical marijuana is chosen, a specific treatment plan for a limited period of time should be agreed on, with details documented in the medical record. The doctor should instruct the patient not to drive or operate heavy machinery while using marijuana.”
Yes, I do that.

“The patient should be seen for follow-up visits to monitor for efficacy and side effects of medical marijuana.”
This is a standard practice with any treatment.

“Patients with a history of mental health problems, substance abuse or addiction should be referred for further evaluation as needed.”
I typically avoid prescribing medical marijuana to such patients.

Another option for the treatment of nausea

By: Dr. Mauskop

14-10-2016

Headache medications, Migraine, New treatments

Nausea is a very common symptom that accompanies migraine attacks. Effective treatment of migraine with a drug like sumatriptan often stops the headache, nausea, and other associated symptoms. However, sometimes pain subsides, while nausea does not, or nausea is much more bothersome than the headache. Nausea can also be a side effect of the most effective injectable migraine drug, dihydroergotamine (DHE-45). We often administer this drug in our office after other injectable drugs (magnesium, sumatriptan, ketorolac, dexamethasone, etc) fail. If nausea is already present, we will always give an intravenous injection of a nausea drug such as ondansetron (Zofran) or metoclopramide (Reglan) before giving DHE. Sometimes these drugs are ineffective in preventing nausea and vomiting induced by DHE and we have to look for other options.

Phenothiazine family of drugs, including prochlorperazine (Compazine), chlorpromazine (Thorazine), and promethazine (Phenergan) are very old and effective anti-nausea drugs. However, they have a potential for a rare but devastating side effect, which consists of persistent involuntary movements of the face (grimacing and lip smacking) and body. The onset of this side effect can be delayed, which is why it is called tardive dyskinesia. It is not unusual for these drugs to cause an immediate severe and very unpleasant restlessness (akathisia), which patients sometimes describe as wanting to crawl out of one’s skin. Metoclopramide (Reglan) can also cause these side effects, but less often.

Ondansetron (Zofran) does not cause any such side effects and should be the preferred drug for nausea of migraine, although it is only approved for nausea caused by chemotherapy or radiation and for post-surgical nausea. Since it has become generic and inexpensive, it can be used for other causes of nausea, including migraines. It is available as an injection or as a tablet.

Aprepitant (Emend) is an anti-nausea drug that has a totally different mechanism of action than the medications described above, so it is possible that it can help when other drugs do not or when other drugs cause side effects.

A study just published in Neurology by Dr. Denise Chou and her colleagues describes the use of oral aprepitant in the treatment of DHE-induced nausea in hospitalized patients.

The authors reviewed hourly diary data and clinical notes of patients admitted to the hospital for the treatment of refractory migraine headaches (status migrainosus) with DHE infusions between 2011 and 2015.

They identified 74 such patients, of whom 24 had daily diaries. In 36 of 57 cases in which aprepitant was given, there was a 50% reduction in the number of other anti-nausea medications given to patients. Of 57 patients, 52 reported that the addition of aprepitant improved nausea. Among 21 of 24 patients with hourly diary data, nausea scores were reduced. In all 12 patients with vomiting aprepitant stopped it. Aprepitant was well tolerated and caused no side effects.

The authors concluded that aprepitant can be effective in the treatment of refractory DHE-induced nausea and vomiting. They also suggested that perhaps this drug could be used for nausea of migraine even when DHE is not given. The only problem, and it is a very big problem, is the cost. This drug is not going to be available in a generic form until 2018. A single capsule of Emend costs $105 with a coupon you can get on GoodRx.com. Without a coupon, it is $145. A single vial for injection costs $345, so we are not going to use this drug for nausea due to migraine or DHE for at least two years, when cheaper generic copies become available.

Low magnesium and growth factor are found in fibromyalgia

By: Dr. Mauskop

14-03-2016

Brain disorders, New treatments, Pain

Fibromyalgia is a condition comorbid with migraine, which means that migraine sufferers are more likely to have fibromyalgia and those with fibromyalgia are more likely to have migraines (such relationships are not always bidirectional). One common finding in these two conditions is low magnesium level and both condition often improve with magnesium supplementation or magnesium infusions.

A new study by Dr. T. Romano of 60 patients with fibromyalgia showed that those who have low red blood cell (RBC) magnesium levels are likely to have low levels of growth hormone (IGF-1, or insulin-like growth factor 1). RBC magnesium level is a more accurate test than the routine serum magnesium level, which is highly unreliable as most of the body’s magnesium sits inside the cells.

Dr. Romano recommends magnesium supplementation and a referral to an endocrinologist. It is possible that treatment with growth hormone will help those who are deficient, although it is also possible that magnesium supplementation alone (oral or intravenous, if oral is ineffective) could increase the production of growth hormone.

Nose surgery relieves migraines?

By: Dr. Mauskop

06-03-2016

Alternative Therapies, Chronic migraine, Migraine, New treatments, Trigeminal and other neuralgias

A patient of mine just emailed me about a recent segment of the TV show, The Doctors, which featured a woman whose severe chronic migraines were cured by nasal surgery. The segment was shot a few weeks after the surgery, so it is not clear how long the relief will last in her case. The surgery involved removing a contact point, which occurs in people with a deviated septum. The septum, which consists of a cartilage in the front and bone in the back, divides the left and the right sides of the nose. If the bony septum is very deviated, which often happens from an injury, it sometimes touches the side of the nose, creating a contact point between the septum and the bony side wall of the nose.
contact point headache
Several small reports by ENT surgeons have described dramatic relief of migraine headaches with the removal of the contact point. If headaches are constant, then the constant pressure of the contact point would explain the pain. However, many of the successfully treated migraine sufferers had intermittent attacks. The theory of how a contact point could cause intermittent migraines is that if something causes swelling of the mucosa (lining) of the nasal cavity, then this swelling increases the pressure at the contact point and triggers a headache. This swelling can be caused by nasal congestion due to allergies, red wine, exercise, and possibly other typical migraine triggers.

This is a good theory, but it is only a theory and the dramatic relief seen after surgery could be all due to the placebo effect. The only way to prove that contact point headaches exist and can be relieved by surgery is by conducting a double-blind study, where half of the patients undergoes surgery and the other half does not. Giving both groups sedation and bringing them to the operating room will blind the patient while the neurologist who evaluates them will also not know who was operated on and who was not, making this a double-blind study. This design is also good only in theory because those who had surgery will have bloody nasal discharge and nasal packing, thus breaking the blind.

However, despite the fact that we will not see any double-blind studies in the near future, there is one way to predict who may respond to contact point surgery. An ENT surgeon can spray a local anesthetic, such as lidocaine, around the contact point during a migraine attack and if pain goes away, then surgery is more likely to help. I would not recommend anyone having surgery without such a test.

Blood thinner for migraine?

By: Dr. Mauskop

25-12-2015

Migraine, New treatments

A hole between the left and the right side of the heart has been suspected to be the cause of migraines in some people. However, closing this hole has not produced dramatic improvement in several blinded studies that have been conducted in the past few years.

The hole, called atrial septal defect (ASD) is present in utero but begins to close as soon as the baby is born. In about 1.5% of the population (in twice as many women than men) the hole does not close completely. In most people this hole is small and does not cause any symptoms. However, if it is big, it requires intervention because it can lead to heart failure and strokes. Smaller ASD may not cause any symptoms, but has been suspected to be related to migraine headaches, especially migraines preceded by a visual aura.

The closure of ASD is done by threading up through a vein in the groin an umbrella-like device which is positioned and opened inside the heart to close the hole. A recent study looked at the need for different blood thinners to prevent blood clots from forming in the heart after the procedure. Half of the 171 migraine patients in the study were given aspirin and placebo and the other half aspirin and clopidogrel, another blood thinner. Interestingly, those who were given two blood thinners (aspirin and clopidogrel) had less severe migraine attacks than those on one (aspirin and placebo). This suggests, that the benefit seen in some of the previous ASD closure studies was due to the blood thinner rather than the procedure itself.

A trial currently under way at the Columbia University Medical Center is examining whether a different blood thinner, Brilinta will improve migraines in those with an ASD. If you’d like to consider participating and want to learn more about the study, go to this website.

Update on Berolina KliniK

By: Dr. Mauskop

15-12-2015

Chronic migraine, New treatments

Inpatient migraine headache treatment in the US is usually limited to a five-day course of intravenous DHE and other medications. Even such brief admissions are not always approved by the insurance companies. Many patients improve after these admissions, but often only for a short time because besides some reduction in pain intensity, very little else changes in the patient’s life and her brain. It makes sense that longer-term inpatient rehabilitation of chronic migraine and pain patients can lead to a major and lasting improvement, but it is almost unheard of in the US. However, it is available in Germany and other countries.

Last November I lectured at one of the leading German inpatient rehabilitation facilities, the Berolina Klinik. My blog post about the Klinik was read by an Englishman with severe chronic migraines who was recently treated there with a three-week program with excellent results. Here is one of the articles that appeared in German press – Westfalen-Blatt 27.10.15.

And, shockingly to us Americans, the cost of treatment is less than $7,000 for a three-week stay in this top facility. Even with travel costs, it’s a bargain. I have been mentioning Berolina Klinik to my patients, although haven’t had anyone make the trip yet.

Zecuity, a transdermal migraine patch is now available

By: Dr. Mauskop

05-10-2015

Headache medications, New treatments

Zecuity, a skin patch containing a migraine drug sumatriptan was approved by the FDA almost two years ago, but it became available (by prescription) only last month (see my previous post about Zecuity). The product is not available in retail pharmacies, only from a specialty pharmacy. The doctor who prescribes the patch will usually provide information on where to get it. Otherwise, go to zecuity.com, where you can find a section entitled Migraine Support Solutions. At this site you can verify that your insurance covers this product, get it shipped to you, and then get information on how to apply the patch. A discount coupon is also available on the site and it promises that the copay will be as low as $15. That is a good thing, because it looks like (on GoodRx.com) each patch costs $300. Yes, not $30, but $300 a piece, or $1,200 for a box of 4. I don’t think too many people will be buying this patch if their insurance does not cover it.

So, who is the best candidate for Zecuity? Half of migraine sufferers experience nausea and/or vomiting with their attacks. This makes the absorption of oral drugs, such as triptans (Imitrex, Maxalt, Zomig, etc) so slow as to make them ineffective. In such patients we try to bypass the stomach, which until now was possible to do with a nasal spray, suppository, or an injection. Sumatriptan (Imitrex) is available in the US in tablets, nasal spray and self-administered injections. Nasal spray of sumatriptan is not very effective, but injections work better than tablets. Relief from an injection can occur in as quickly as 10 minutes, but injections can cause more side effects, which are mostly unpleasant rather than dangerous. Obviously, most people would rather not get a shot. One form of injectable sumatriptan delivers the medicine through the skin without a needle (Sumavel), but not without pain see this post.

One other triptan, zolmitriptan (Zomig) is available in a nasal spray and it is more effective than sumatriptan nasal spray, but it is not available in a generic form, making it less accessible because of the high cost and restricted insurance coverage.

The perfect patient for Zecuity is someone who experiences nausea and/or vomiting with their migraine attacks and who does not respond to tablets and has side effects from or aversion to injections. Zecuity provides good relief for such patients with the main side effect being skin irritation from the patch. The patch is fairly large, the size of a palm. It uses a miniature battery to generate an electric current, which helps drive the medicine through the skin. Iontopheresis is the name of this process. Iontopheresis has been known for decades, but Zecuity is the first product approved by the FDA to utilize this technology.

Disclosure – Teva Pharmaceuticals, manufacturer of Zecuity pays me to give lectures about Zecuity to doctors.

Previous Next

Allergan Announces Positive Results for Ubrogepant – an Oral CGRP Receptor Antagonist for the Acute Treatment of Migraine

Breakthrough in the treatment of migraines

More on intravenous ketamine for migraines

New research on cannabis for migraines

A new drug is approved for temporal arteritis, cause of headaches in those over 50

Guidelines for the use of medical marijuana

Another option for the treatment of nausea

Low magnesium and growth factor are found in fibromyalgia

Nose surgery relieves migraines?

Blood thinner for migraine?

Update on Berolina KliniK

Zecuity, a transdermal migraine patch is now available

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