Headache NewsBlog

Update: I injected myself with Aimovig (erenumab) and here’s what happened so far

By: Dr. Mauskop

10-06-2018

On June 1, I injected myself with erenumab (Aimovig). I still had to take sumatriptan for an incipient migraine on June 2 and June 5. On Thursday, June 7, I had a glass of red wine (pinot noir) with dinner and had no headache. Last night, June 9, I decided to stress-test my response to erenumab and had a beer before dinner and a big glass of sparkling wine with dinner. In the past, this combination had always resulted in a migraine a few hours later. This time, nothing happened!

And here is an excerpt from an email from a patient who was one of the first to receive Aimovig:

“Hello Doctor,
It has been a week now and I wanted to share with you the outcome.
It’s a very important improvement as I was able to stop taking Relpax compared to 40mg a day!
3-4 times I felt the migraine coming but it was like « stopped » and I was feeling ok.
It happened during the day and at night twice.
Overall it’s a fantastic improvement.”

Certainly, this all could be due to the placebo effect, but I doubt it, especially because my migraines did not stop right after the injection. I should stress that erenumab is not going to help everyone. Clinical trials suggest that about 60% of migraine sufferers will benefit, but this is a very high success rate, especially considering the lack of any significant side effects.

Cheers!

100 Migraine Drugs, A to Z: botulinum toxin

By: Dr. Mauskop

07-06-2018

Botox, Headache medications, Migraine

The FDA has approved 4 different types of botulinum toxin for various therapeutic indications. The oldest, the most popular and the only one approved for the prevention of chronic migraines is onabotulinumtoxinA, or Botox. I’ve been injecting Botox for headaches for over 25 years and have written many blog posts and long articles about it. You can read about Botox for kids with chronic migraines in this post.

A new development in the botulinum toxin field is a long-acting form of botulinum toxin, daxibotulinumtoxinA , which may become available in a couple of years. Its effect on muscles and nerve endings appears to last 6, instead of the 3 months seen with Botox.

100 Migraine drugs, A to Z: Atenolol

By: Dr. Mauskop

04-06-2018

Headache medications

Atenolol (Tenormin) is a blood pressure medicine in the beta blocker family. Atenolol is considered to be equally effective in preventing migraines to propranolol (Inderal), which was the first drug to be approved for the prevention of migraines over 50 years ago. The effect of atenolol lasts all day and it can be taken once a day. It has the same side effect profile as propranolol. The most common side effects are caused by excessive lowering of blood pressure or slowing of the pulse rate and include fatigue, lightheadedness, exercise intolerance, cold extremities, and occasionally impotence, depression and insomnia. Some but not all beta blockers can worsen asthma.

You do not have to have high blood pressure to take atenolol or another beta blocker – they prevent migraines even if blood pressure is normal. We still do not know how these drugs prevent migraines. We do not prescribe beta blockers if the blood pressure is low (below 110/70) because the risk of side effects is high. However, if the blood pressure is in the middle of normal range or higher, this is a good choice. Beta blockers also help with anxiety and many performers take them only before giving a speech, a presentation, or a musical performance. Under these circumstances, a short-acting beta blocker, such as propranolol is a better choice than atenolol. Beta blockers are also very effective for the benign essential or familial tremor.

I just injected myself with erenumab (Aimovig)

By: Dr. Mauskop

02-06-2018

Headache medications, Migraine, New treatments

As expected, we’ve been overwhelmed by the demand for the new preventive therapy for migrianes, erenumab (Aimovig). It offers a unique and highly effective therapy with virtually no known side effects, at least so far.

My patients are usually glad to hear that I have migraines (without an aura, but I also have auras without a headache) because I can better relate to their experience. They often ask if I had tried this or another treatment and indeed, I’ve tried many, sometimes less out of necessity but more for the experience. I have never tried drugs such as topiramate (Topamax) or divalproex (Depakote) because they have many potentially serious side effects and I prescribe them very reluctantly after trying many other treatments. I have injected myself with Botox on two occasions, have given myself a nerve block and an intravenous infusion of magnesium.

Luckily, even when I have periods of very frequent attacks, my migraines are easily controlled with sumatriptan tablets or injections. I prefer injections when I want quick relief, such as before going to bed, in the middle of the night, or during a busy work day.

Although over 3,000 patients have been exposed to erenumab in clinical trials and some of them have been on it for 5 years, the true safety of the drug may not be known for at least another 3-5 years.

Even though my migraines do not cause any disability or interfere with my life (except for the need to avoid wine), in the tradition of doctors experimenting on themselves, yesterday I gave myself a shot of erenumab. It was painless and caused no local reaction, which is the most common side effect seen in 5%-6% of patients. This lack of serious and not so serious side effects has been the most surprising aspect of not only erenumab, but also of the other 3 CGRP monoclonal antibodies in development. So admittedly, injecting myself with erenumab was not an act of bravery and I really did it to see if I can drink more wine and take less sumatriptan.

Cannabis relieves pain in the elderly

By: Dr. Mauskop

23-05-2018

Alternative Therapies, Headache medications, Pain, Pain Research

Medical marijuana appears to be very effective for the treatment of pain, according to a new study just published in the European Journal of Internal Medicine.

The study was conducted by researchers at the Soroka University Medical Center, Ben-Gurion University of the Negev, in Be’er-Sheva, Israel. Israeli scientists have been at the forefront of the research of medical applications of cannabis, starting with the discovery of THC in 1964 by a Hebrew University professor Raphael Meshulam.

In the current study, the researchers evaluated 2736 patients above 65 years of age who received medical cannabis from January 2015 to October 2017 in a specialized medical cannabis clinic. The mean age was 74 years. The most common indications for cannabis treatment were pain (67%) and cancer (61%). After six months of treatment, 94% of the respondents reported improvement in their condition and the reported pain level was reduced from a median of 8 on a scale of 0-10 to a median of 4. Most common adverse events were dizziness (9.7%) and dry mouth (7.1%). After six months, 18.1% stopped using opioid (narcotic) analgesics or reduced their dose.

The authors concluded that “the therapeutic use of cannabis is safe and efficacious in the elderly population. Cannabis use may decrease the use of other prescription medicines, including opioids.” Even though it was a very large study, it was an observational study with its obvious limitations. They also stressed the need for double-blind prospective trials to confirm the safety and efficacy of medical cannabis for the treatment of pain in the elderly.

A very promising new treatment for cluster headaches

By: Dr. Mauskop

21-05-2018

Cluster headaches, Headache medications

A new and very promising preventive treatment for cluster headaches being developed by Eli Lilly may become available in the near future. We hope that the FDA recognizes that this is a relatively rare condition with few available treatments and will not require extensive clinical trials, especially because the safety of this drug has been demonstrated in a large number of migraine patients.

CGRP monoclonal antibodies are very effective for the prevention of migraines and four companies are developing such drug. Thankfully, one of these companies, Eli Lilly decided to study this type of treatment for cluster headaches. The company just announced the results of a phase 3 trial in 106 patients that showed their product, galcanezumab to be effective in preventing episodic cluster headaches. The drug did not help prevent attacks in patients with chronic cluster headaches, which constitute 10-15% of cluster patients.

Last week, the first CGRP monoclonal antibody, erenumab (Aimovig) was approved for the preventive treatment of migraine headaches. Considering that all four CGRP drugs are similar, it is possible that erenumab is also effective for cluster headaches. However, because it was not studied for this indication and has no FDA-approval, insurance companies are not likely to pay for it. On the other hand, cluster attacks last one to three months, so the cost is less prohibitive than it is for the long-term treatment of migraines and patients are more desperate to find relief at any cost.

Cluster headaches affect less than 0.5% of the population (mostly men), but they are often excruciating and sometimes described as suicidal. The name cluster comes from the fact that these headaches occur daily for a month or two and then go away for a year. Chronic cluster headaches continue to occur for more than a year without a break. Each attack lasts anywhere from 15 minutes to a couple of hours, often waking the patient from sleep, usually at the same time of night. The pain is always on one side, around the eye and sometimes at the back of the head. Besides pain, patients experience tearing and nasal congestion on the side of the headache. Unlike with migraine, where patients try to lie quietly and not move, cluster attacks lead to agitation, restlessness, pacing and even hitting the head with a fist or against a hard object.

The only FDA-approved treatment for cluster headaches is injection of sumatriptan (Imitrex, Imigran) to abort each individual attack. This drug is also approved for migraines, indicating that there are similarities between these conditions. Other abortive treatments included inhalation of oxygen and intranasal zolmitriptan (Zomig NS), while tablets tend to be too slow to work. For prevention, we use occipital nerve blocks, a course of steroids or daily drugs, such as verapamil (Calan).

Most of these older treatments work for about 50% of patients, so it is very exciting to have a highly effective treatment that was specifically developed for cluster headaches.

Migraine drugs, A to Z: timolol eye drops

By: Dr. Mauskop

19-05-2018

Headache medications, Migraine

Propranolol (Inderal) and other blood pressure medications in the beta blocker family are effective for the prevention of migraines. In a previous post 4 years ago I mentioned a report of 7 patients whose migraines were aborted with beta blocker, timolol, eye drops that are used to treat glaucoma.

The same group of doctors at the University of Missouri, Kansas City conducted a double-blind crossover study of timolol eye drops for the treatment of acute migraines. The results of the trial were published this month in JAMA Neurology. The treatment consisted of 4 drops of 0.5% timolol (this compares with 10 to 30 mg dose taken orally. Ten patients treated almost 200 migraine attacks. Four participants found timolol highly effective compared with placebo and one patients rated placebo as highly effective compared with timolol. No side effects were observed.

Instilling timolol eye drops is not likely to become widely used for the treatment of acute migraines. However, this treatment maybe worth trying in patients who do not respond or do not tolerate triptans and NSAIDs.

Aimovig (CGRP monoclonal antibody) is approved by the FDA!

By: Dr. Mauskop

18-05-2018

Uncategorized

Yesterday the FDA approved the long-awaited breakthrough drug for the prevention of migraines. It promises to provide relief to two out of three migraine sufferers with minimal side effects.

It should become available in a couple of weeks. The cost of the monthly injection is $575, but hopefully most insurance plans will cover it. The insurance companies are likely to require that the patient first try and fail a couple of inexpensive drugs before paying for Aimovig, as they do with Botox.

The medicine comes in a simple-to-use auto-injector and after the initial injection patients will be able to self-administer it.

To patients of the New York Headache Center – please call the office and schedule an appointment.

100 Migraine drugs, A to Z: Amlodipine

By: Dr. Mauskop

16-05-2018

Headache medications

Calcium channel blockers, a family of drugs used to treat hypertension, are sometimes used for the prevention of migraine headaches. Anecdotal reports suggest that verapamil (Calan) can treat migraine with aura and other neurological symptoms. Double-blind trials of verapamil for the prevention of migraines have been unconvincing. Verapamil seems to be more effective for the prevention of cluster headaches, but even there the evidence is anecdotal.

Amlodipine (Norvasc) is another calcium channel blocker that has been reported to prevent migraine headaches, although reports include a very small number of patients. Since verapamil has been studied more extensively, it is usually used first. However, if verapamil works well but causes constipation, which can be severe, we usually switch to amlodipine. Amlodipine is less likely to cause constipation, but both drugs can cause swelling of the ankles, dizziness and other side effects.

100 Migraine drugs, A to Z: Amitriptyline

By: Dr. Mauskop

14-05-2018

Headache medications

Amitriptyline (Elavil) and other drugs in the family of tricyclic antidepressants have been proven to be very effective in the preventive treatment of migraine headaches and many other painful conditions.

Several double-blind, placebo-controlled trials have proven the utility of amitriptyline for the prevention of migraines. Amitriptyline is also an effective antidepressant, so it is perfect for patients with anxiety or depression. However, its effect on migraines and pain is proven to be independent of its effect on depression. That is, even in the absence of depression or anxiety, the drug prevents migraines and relieves pain.

Amitriptyline has an additional benefit for people with insomnia – it helps sleep. On the other hand, in some people this effect lasts too long and they feel sleepy or tired the next day. In such cases we try a different and less sedating tricyclic antidepressant, such as nortriptyline (Pamelor), desipramine (Norpramine), or protriptyline (Vivactil). This potential side effect is why we always start this and most other preventive drugs at a small dose, 10 or 25 mg nightly. Some people need only 25 mg, while other require 100 mg. This is often due to the variable absorption of the drugs. Fortunately, in case of amitriptyline a simple blood test can tell us how much of the drug is being absorbed. Some patients will achieve a good therapeutic level with 25 mg, while others need 100 or 150 mg. So, in the absence of side effects and lack of relief, the dose is slowly increased. When we get to 75 or 100 mg, blood test can provide guidance about the safety of further escalation of the dose.

High levels of tricyclic antidepressants can be dangerous, leading to arrhythmias – irregular heart rhythms. We usually obtain an electrocardiogram in the elderly and those at risk for heart disease before starting amitriptyline. Two other more common side effects of amitriptyline are constipation and dry mouth. In many patients constipation can be successfully managed with over-the-counter remedies, such as Senokot S or Miralax.

100 Migraine drugs, A to Z: amiloride

By: Dr. Mauskop

12-05-2018

Headache medications, Migraine

Only about 20% of migraine sufferers experience an aura. The most common type of aura is visual and it typically consists of partial obscuration of vision with colorful zigzags and blind spots spreading over half of the visual field of both eyes. Sometimes, the aura consists of gradual narrowing of the visual fields which ends in tunnel vision or complete loss of vision. The typical duration is 20 to 60 minutes and usually the aura itself is not disabling, but the headache that follows can be more severe than during attacks without aura. Migraine aura can occur without a subsequent headache. In some people aura does interfere with normal functioning and can be more disabling than the headache. In rare instances, the visual disturbance persists for days, weeks, and months.

In such cases I do a battery of blood tests, including for RBC magnesium, vitamin B12, homocysteine, CoQ10 levels, and other. If RBC magnesium level is low or at the bottom of normal range, a gram of magnesium sulfate given intravenously can abort the aura. We sometimes give an infusion of magnesium without first doing a blood test.

Amiloride (Midamore) is a potassium-sparing diuretic (water pill), which means that unlike most diuretics, it does not deplete potassium. It is used to treat high blood pressure, heart failure and to remove excess fluid in the body. It has been reported to reduce aura and headache symptoms in 4 of 7 patients with otherwise intractable aura. Potential side effects of amiloride include dizziness, nausea, stomach pain, and diarrhea.

Other diuretics, such as acetazolamide, which is also used for barometric pressure-induced migraines and furosemide have also been reported to stop a prolonged visual aura. Other approaches to treat a persistent aura include the use of preventive migraine medications, such as a blood pressure medication, verapamil (Calan) or one of the epilepsy drugs, such as topiramate (Topamax), divalproex sodium (Depakote), or lamotrigine (Lamictal). An infusion of divalproex sodium derivative, valproic acid (Depakene) can be also tried.

100 Migraine drugs, A to Z: Alpha-lipoic acid

By: Dr. Mauskop

09-05-2018

Headache medications, Migraine

Alpha-lipoic acid is one of the natural supplements included in this list of 100 migraine drugs. According to a study by Magis and colleagues, a daily dose of 600 mg of alpha- lipoic acid (known as thioctic acid in some countries) was significantly better than placebo in reducing the frequency of migraine attacks, headache days and pain severity. No side effects were reported in this 44-patient study. However, some of my patients have complained of upset stomach, which is not surprising since it is an acid. This was a small study and it does not conclusively prove that alpha-lipoic acid relieves migraines.

The use of this supplement is most proven in the treatment of peripheral neuropathies, which suggests that it may work for other neurological conditions such as migraine. Alpha-lipoic is being investigated as a treatment for multiple sclerosis, Alzheimer’s, diabetes, strokes and other conditions.