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Tag "Imitrex"

Triptans, such as Imitrex or sumatriptan and similar drugs are “designer” drugs which were developed to specifically treat migraine headaches. They are highly effective and, after more than 20 years on the market, proven safe. Four out of the seven drugs in this category (Imitrex, Maxalt, Zomig, Amerge) are available in a generic form, which significantly lowers their cost, which was one of the obstacles for their widespread use. So, it would appear that now there is no reason for doctors not to prescribe triptans to migraine sufferers.

In 1998, emergency department doctors gave more than half of the patients suffering from migraine headaches opioids (narcotics) to relieve pain and, according to a new study, 12 years later, this hasn’t changed.

Despite the fact that triptans are widely considered to be the best drugs for acute migraine, the use of these drugs in the emergency department has remained at 10%, according to a study led by Benjamin Friedman, an emergency medicine doctor at the Montefiore Medical Center in the Bronx.

In 1998, about 51% of patients presenting with migraine at the emergency department were treated with an injection of a narcotic and in 2010, narcotics were given to 53% of the patients.

Other than narcotics (opioids) emergency department doctors often give injections of an NSAID (non-steroidal anti-inflammatory drug) Toradol (ketorolac) or a nausea drug, such as Reglan (metoclopramide). These two drugs are more effective (especially if given together) and have fewer potential side effects than narcotics. They also do not cause addiction and rebound (medication overuse) headaches, which narcotics do.

Dr. Friedman and his colleagues looked at the national data for 2010 and found that there were 1.2 million visits to the emergency departments for the treatment of migraine. Migraine was the 5th most common reason people come to the emergency room.

They also discovered that people who were given a triptan in the emergency department had an average length of stay in the ER of 90 minutes, while those given Dilaudid (hydromorphone) – the most popular narcotic, stayed in the ER for an average of 178 minutes.

Opioids should be used only occasionally – when triptans, ketorolac, and metoclopramide are ineffective or are contraindicated. This should be the case in maybe 5% of these patients, according to Dr. Friedman

One possible reason why ER doctors do not follow recommended treatments and use narcotics instead, is that they do not recognize a severe headache as migraine and misdiagnose it as sinus, tension-type or just as a “severe headache”. Many doctors still believe that migraine has to be a one-sided headache, or a visual aura must precede a migraine, or that the pain has to be throbbing. It is well established that none of these features are required for the diagnosis of migraine.

Another possible reason for the widespread use of opioid drugs in the ER is that doctors are very accustomed to using them, while triptans may be unfamiliar and require thinking about potential contraindications, what dose to give, what side effects to expect, etc.

In summary, if you or someone you know has to go to an ER with a severe migraine, ask for injectable sumatriptan (which you should have at home to avoid such visits to the ER) or ketorolac.

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Intranasal sumatriptan powder seems to be a new and very promising way to deliver a migraine drug.  Sumatriptan (Imitrex) nasal spray has been available for many years, however it is not very effective or at least is not consistently effective.  The liquid tends to leak out of the nose, get swallowed, or just not get absorbed.  Nasal spray of Zomig (zolmitriptan) appears to be more effective, perhaps because of the smaller volume of the liquid and a finer spray particles.  The new product, OptiNose nasal powder seems to be even more effective.  It is a sophisticated device which does not allow for the powder to enter the lungs and deposits the medicine only in the nasal cavity.  In a study of 117 patients, 57% were pain-free and 80% had pain relief 2 hours after receiving 20 mg of sumatriptan powder, which was very significantly better than with placebo.  The nasal powder seems to be three times more effective than the nasal spray and almost as effective as an injection.  We hope that the FDA will approve this product in the near future.

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A new treatment for motion sickness in patients with migraines was reported by a group of doctors from Pittsburgh.  Giving migraine sufferers who are prone to motion sickness a migraine drug, rizatriptan (Maxalt) prevented motion sickness . There were 25 subjects in the study and 15 of them developed motion sickness after being rotated in the darkness. Of these 15 patients, 13 showed decreased motion sickness after being pretreated with rizatriptan. This was a small study and not all patients benefited, but this is an option that should be considered in patients who suffer from severe motion sickness.  It is likely that the effect is not specific to rizatriptan, but that sumatriptan (Imitrex), eletriptan (Relpax) and other triptans are also effective.  However, just like when treating migraine attacks, it is possible that some patients will respond better to one triptan and others to another.

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Severe migraines are often accompanied by nausea and vomiting, making oral medications ineffective.  Sumatriptan (Imitrex) and Zomig (zolmitriptan) are available in a nasal spray and Imitrex also as an injection (a needleless injection, Sumavel was launched recently).  Nasal spray is not well absorbed and does not work well for many (in my experience, Zomig spray is somewhat better than Imitrex).  Injections work fast, but are painful (even the needleless injection hurts) and expensive.  Another way to get medicine into the body is rectally.  Rectal suppositories are absorbed very quickly and more consistently than nasal sprays.  Europeans are much more receptive to this route of administration than the Americans.  A group of Italian researchers compared  the effect of a suppository containing 25 mg of sumatriptan with a 50 mg tablet.  The suppository was slightly more effective than the tablet.  Imitrex suppositories are not available, but so called compounding pharmacies can prepare a suppository of any medication, if doctor writes an order.  With Imitrex going generic, the price should be more affordable.

There are two other products in development (not yet available), which will bypass oral route – a sumatriptan skin patch and an inhaler of dihydroergotamine (Levadex).  The patch is somewhat large and may be awkward to use, while the inhaler is much more promising.  Inhaling a drug into the lungs provides very fast onset of action, faster than subcutaneous injection of Imitrex.  According to the published data the efficacy of Levadex is very good with few side effects.

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During pregnancy, two thirds of women stop having migraine headaches.  However, one third continues to have them, and sometimes even worsen during pregnancy.   As a general rule, only acetaminophen (Tylenol) is considered safe, but for most migraine sufferers it is completely ineffective.  Codeine is also benign, but it also either does not work or causes side effects, such as nausea and sedation.  Triptans, such as sumatriptan (Imitrex), rizatriptan (Maxalt), and other are very effective for migraines, but are not proven to be as safe.  Pregnancy registries in the US have information on over 1,500 women who took a triptan during pregnancy and so far the drugs look safe for the baby.  A new study from Norway in the February issue of Headache reports on another 1,535 women who took triptans during pregnancy and compared them to 68,000 women who did not.  This study also found no increased risk of congenital malformation, even if triptans were taken in the first trimester.  Women who took triptans in the second and third trimester also had healthy babies, but they had a slightly increased risk of atonic uterus and bleeding during labor.

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Needle-free injection of sumatriptan (Imitrex) was tested for its ease of use and for its bioequivalence in a study led by Dr. Jan Brandes.  The new device that provides needle-free subcutaneous injections was easy to use and if injected into the thigh or abdomen (but not the upper arm) delivered the same amount of medicine as an injection with a needle.  Unfortunately, needle-free does not mean pain-free, so the injection still hurts.  This device, when it is approved by the FDA, may be useful for those patients who are afraid of needles.  Many migraine sufferers still do not know that injections of sumatriptan can be easily self-administered using a pen-like device that does contain a needle.  Many doctors do not offer this option because they do not think that patients will readily accept an injection or because they don’t realize how severe the migraines are.  I see many migraine sufferers who gladly take an injection over the tablet.  It is particularly effective for people who have severe nausea and vomiting with their migraine.  The speed of relief is another reason to take an injection – some patients wake up with a migraine and have to go to work or take care of their children and cannot wait for 1-2 hours before the tablet provides relief.  I have taken sumatriptan injection many times myself.  Usually the tablet works for me, but if before going to bed I have a headache from the wine I had with dinner, I will often opt for a shot.  The shot works within 10-15 minutes and allows me to fall asleep right after that, while a tablet may take an hour or longer.

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Imitrex 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.

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