A blinded study comparing Botox with Topamax for the prevention of migraine headaches was conducted by Drs. Jaffri and Mathew and published in the current issue of Headache. They enrolled 60 patients and divided them into two groups – one group received real Botox and placebo tablets, while the second group received saline water injections instead of Botox, but were given tablets of Topamax. At the end of 9 months and after 2 Botox treatments the efficacy of these two treatments was the same, but many more patients in the Topamax group developed side effects and dropped out of the study.
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Migraine headaches in patients with post-traumatic stress disorder tend to be more frequent and disabling, according to a study in soldiers led by Dr. Jay Erickson. Soldiers with PTSD had almost twice as many headaches as soldiers without PTSD and were more likely to have chronic migraines (headaches on more than 15 days a month). Treatment with preventive medications was slightly less effective in the PTSD group. Botox injections were not tried in these patients. It is a well established fact that patients with a history of abuse are more likely to have chronic pain, including headaches. This is an important part of history since inclusion of psychotherapy may improve treatment outcomes in these patients and, at least in theory, using antidepressants rather than other classes of preventive drugs may be more appropriate.
Read More15,056 patients with migraine and tension-type headaches were treated with acupuncture in a largest acupuncture study, which was financed by the German government. Results published in the latest issue of journal Cephalalgia by S. Jena and colleagues indicate that “acupuncture plus routine care in patients with headache was associated with marked clinical improvements compared with routine care alone”. This study should dispel any remaining doubt about the efficacy of acupuncture in the treatment of headaches.
Read MoreMigralex is an over-the-counter medication for the treatment of headaches, which will become available in November of 2009. Results of the first study of Migralex were presented at the annual scientific meeting of the American Headache Society in Boston. In an open-label study 50 patients with headaches who were being treated at the NYHC compared Migralex with their usual medication. Half of the patients found Migralex better or much better than their usual treatment and 27 were willing to take it again. In 31 of 50 patients the usual medication was a triptan ( a prescription migraine medication) and in 19 it was a prescription or over-the-counter pain medication. Migralex was well tolerated, with only one patient reporting upset stomach.
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 MoreScientists in Trieste, Italy suggested a new approach to the treatment of migraine headaches. They hypothesized that combining two different approaches would yield better outcomes than either one alone. A neurotransmitter CGRP antagonists appear to be effective in the treatment of an acute migraine. Merck has a product in late stages of development that works through this mechanism and hopefully will be the first of a new class of migraine drugs. Based on laboratory research the Italian group suggests that combining a CGRP antagonist with a blocker of nerve growth factor may result in a more effective treatment. This fits with a new trend in treatment of many conditions – combining drugs that work in different ways, rather than trying to always use a single medication.
Read MoreTreatment of migraines leaves a lot to be desired and in part not because we do not have effective treatment, but because of a communication barrier. Doctors appear not to want to hear what migraine patients have to say about their headaches, according to a remarkable study by a top headache researcher Richard Lipton and his colleagues. Patients and doctors agreed to be videotaped during a visit and 60 such interactions were analyzed. The analysis showed that doctors did not ask about the disability of headaches and tended to ask closed-end short questions. Very often the information they did obtain was incorrect. 55% of doctor-patient pairs were misaligned regarding frequency of attacks; 51% on the degree of impairment. Of the 20 (33%) patients who were preventive medication candidates, 80% did not receive it and 50% of their visits lacked discussion of prevention. The authors recommended that doctors assess impairment using open-ended questions in combination with what is called the ask-tell-ask technique.
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 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 MoreClopidogrel, which is also known as Plavix, is a drug used to prevent strokes and heart attacks. It works by preventing platelets from sticking together and causing a blood clot which can block a vessel in the heart or brain. Platelets also tend to become sticky in patients during a migraine attack, which is how this drug might help migraine sufferers. A British physician reported that a small number of patients given this drug stopped having migraine headaches after many years of unsuccessful treatments. A large study is currently under way to prove that this drug in fact works better than a placebo.Â
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