In addition to an injection, tablet and a nasal spray, sumatriptan is being tested in two other formulations. No, it is not an inhaled form, which I just posted in my previous blog (dihydroergotamine inhaler), but through a skin patch and by a “lingual spray”, that is a spray into the mouth. The skin patch may work fast and will deliver medicine through the skin, bypassing the stomach, which would be very useful for people who get very nauseous and have difficulty swallowing medications. However, it is quite a large patch and will probably cost significantly more than a tablet, particularly in the generic form. The second new formulation, a spray into the mouth, appears to partially absorb in the mouth and partially in the stomach, making it also work faster, although so far it looks to be only as effective as a 50 mg tablet. The usual dose is 100 mg. Also, hopefully the company that is developing this product has been able to mask the taste of sumatriptan. Patients who have tried the nasal spray often complain of a very unpleasant taste, which can make nausea worse.
Written by Dr. Mauskop | 27.06.2009 | No comments
Trials of an inhaled version of an old migraine drug show surprisingly good results. The drug is dihydroergotamine and in injectable from is considered to be one of the strongest migraine medications. It is often used intravenously to treat severe migraines that do not respond to other therapies and for medication overuse headaches. It can be also injected into the muscle, under the skin or sprayed into the nose. The main problem with this drug is that it often makes nausea worse or even causes severe nausea in patient who do not have it. What is surprising about the new product being developed by MAP Pharmaceuticals is not that is is very effective, but that it causes significantly less nausea than the same drug in an injectable form. Another advantage is that inhaling the medicine into the lungs results in a very quick delivery of the drug into the circulation - as quick as an injection but without a needle. A similar product, Ergotamine Medihaler was available until about 15 years ago, but was withdrawn because of manufacturing difficulties and limited demand. The demand for this new product will also be limited because it will be more expensive than a tablet of any migriane drug, it will be more bulky to carry around, and will be mostly utilized by patients who cannot take oral medications due to nausea or by those who need very quick onset of action to abort an attack.
Written by Dr. Mauskop | 25.06.2009 | 5 comments
Lower facial pain during a migraine attack occurs in 9% of migraine patients, according to a recent report published in Cephalalgia by German researchers. One of the 517 migraine patients they looked at had lower facial pain as the leading symptom of migraine. Some of my patients with lower facial pain wonder if they have a disorder of the temporo-mandibular joint (TMJ). Some of them do benefit from an oral appliance that reduces grinding and clenching, in most however, a successful treatment of their migraines with abortive or prophylactic medications will often relieve the jaw pain as well.
Written by Dr. Mauskop | 22.06.2009 | No comments
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.
Written by Dr. Mauskop | 22.06.2009 | No comments
Occipital nerve stimulation appears to be a promising new treatment for migraine and cluster headaches. Phase II trials performed by Medtronics, the manufacturer of one type of stimulator, have been positive. This stimulator requires implantation of a stimulator wire next to the occipital nerves and a separate incision to implant a stimulator device with a battery in the upper chest. A recent report suggests that the same effect can be achieved by implanting a small self-contained device without the need for wires, large battery, or a separate incision. This “Bion Microstimulator” has not been subjected to any extensive studies similar to ones performed by Medtronics, but the preliminary data looks promising.
Written by Dr. Mauskop | 26.05.2009 | No comments
Headache diary plays an important role in the management of headache patients. Drs. McKenzie and Cutrer from the Mayo Clinic compare patient recall of migraine headache frequency and severity over 4 weeks prior to a return visit as reported in a questionnaire vs a daily diary. Here are some of their findings “Many therapeutic decisions in the management of migraine patients are based on patient recall of response to treatment. As consistent completion of a daily headache diary is problematic, we have assessed the reliability of patient recall in a 1-time questionnaire. 209 patients completed a questionnaire and also maintained a daily diary over the 4-week period. RESULTS: Headache frequency over the previous 4 weeks as reported in interval questionnaires (14.7) was not different from that documented in diaries (15.1), P = .056. However, reported average headache severity on a 0 to 3 scale as reported in the questionnaire (1.84) was worse than that documented in the diaries (1.63), P < .001. CONCLUSIONS: In the management of individual patients, the daily diary is still preferable when available. Aggregate assessment of headache frequency in groups of patients based on recall of the prior 4 weeks is equally as reliable as a diary. Headache severity reported in questionnaires tends to be greater than that documented in daily diaries and may be less reliable. “
Written by Dr. Mauskop | 22.05.2009 | 2 comments
A pharmacogenetic study by Italian researchers discovered that absence of a certain gene can predict therapeutic response in migraine patients who are treated with riboflavin (vitamin B2). Pharmacogenomics has been a very promising field of medical science that may enable doctors to select the most effective and safe medicine for each patient based on their genetic profile. This is a small but important step in utilizing this science to treat headache patients.
Written by Dr. Mauskop | 12.05.2009 | No comments
Vertigo is a common symptom in patients with migraine headaches. It appears that obverse is also true - migraine is very common in patients with vertigo. A study just published in Cephalalgia looked at 208 patients with benign recurrent vertigo. It turned out that 87%, or 180 of these patients had migraine headaches. Of these 180 patients, 112 or 62% had migraine with aura and 38% had migraine without aura. Thirty percent, or 54 patients always had vertigo without any migraine symptoms, while in 70% vertigo occurred with a headache or other migraine symptoms, such as visual aura, sensitivity to light and noise. The duration of attacks of vertigo in most patients was between one hour and one day.
Written by Dr. Mauskop | 20.04.2009 | 5 comments
Botulinum toxin, which most people know as Botox is produced by a bacteria - Clostridium botulinum. This bacteria actually produces 7 different type of this toxin: A, B, C, D, E, F, and G. Botox is botulinum toxin, type A, while another commercial product, Myobloc is botulinum toxin, type B. Researchers, Drs. Dolly, Aoki and their colleagues managed to combine type A and E, according to a report in The Journal of Neuroscience. Test tube experiments suggest that this combination could prove to be more effective for the treatment of pain than type A alone. This is a very promising discovery, since Botox is effective for only about two thirds of chronic migraine sufferers. The combined toxin could be also effective for other types of pain.
Written by Dr. Mauskop | 19.04.2009 | No comments
Dr. Rami Burstein of Harvard University and his colleagues discovered the way to predict who is going to respond to Botox injections. Patients who have pain that is constricting, crushing, or “imploding” with pressure going from outside in and those with pain in the eye respond much better than those whose pain is “exploding” or with a sensation of pressure building up from inside the head. This was true for patients with episodic, as well as chronic migraine headaches. About 83% of non-responders had “exploding” headaches and 84 of responders had “imploding” headaches. Fortunately, many more patients suffer from imploding headaches or headaches with pain in the eye than with “exploding”headaches.
Written by Dr. Mauskop | 11.04.2009 | No comments
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