Headache NewsBlog

Intravenous medications for trigeminal neuralgia

Dr. Mauskop — Thu, 23 May 2013 02:26:48 +0000

Trigeminal neuralgia is an extremely painful condition that causes electric-like pain in the face. It is often misdiagnosed as a dental problem, sinus headache or another condition. The pain is very brief, just like an electric shock, but it can occur continuously and is often triggered by brushing teeth, chewing, talking, or even by wind. This is a very treatable condition and it usually responds to anti-epilepsy drugs, Botox injections and, if those fail, surgery. Many patients have periods of sudden worsening of pain and until medications or Botox begin to help they need emergency treatment for pain. Narcotics (opioids) are usually ineffective. Dr. Merritt and Cohen of the Beth Israel Hospital in New York recently described the use of intravenous antiepileptic medications for acute exacerbations of trigeminal neuralgia in the emergency department. They described 21 patients, 15 women and 6 men whose aged ranged from 33-88 and the mean age was 69 (trigeminal neuralgia is more common in the elderly). 19 received intravenous fosphenytoin (Cerebyx, a drug related to an oral drug Dilantin) 2 received levetiracetam (Keppra) with excellent relief. Side effects included double vision, dizziness, sleepiness, and itchiness with fosphenytoin and no side effects were observed in 2 who received levetiracetam. Unfortunately, the most commonly used oral drugs for trigeminal neuralgia, carbamazepine (Tegretol) and oxcarbazepine (Trileptal) are not available in an injectable form. Another epilepsy drug, divalproex sodium (Depakote) can be given intravenously (Depakene) but it does not appear to be very effective for trigeminal neuralgia.

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Another triptan is going generic

Dr. Mauskop — Fri, 17 May 2013 12:21:44 +0000

Zomig (zolmitriptan) is the fourth triptan (out of seven) to become available in a generic form. This spells big relief for migraine sufferers who rely on this drug. Only tablets and orally disintegrating tablets (ZMT) will become available, not the nasal spray. Nasal spray offers faster relief and for some patients it is as fast as sumatriptan injection (Imitrex, Sumavel, Alsuma). It may take another 6 months for the price to drop significantly from the current $30 to $45 a pill because at this point only four companies are coming out with a generic version. There are about 10 manufacturers making generic Imitrex. Generic sumatriptan (Imitrex) is now available for $3 a pill, while the other two generics, Maxalt (rizatriptan) and Amerge (naratriptan) are still more expensive.

One caveat with the generics is that the quality sometimes is not as good as that of the brand. Of approximately 10 generic sumatriptan versions, my patients have found that 2 are very ineffective. One of these two manufacturers which is based in India (Ranbaxy), recently paid $500 million fine to the FDA for improper manufacturing, storing and testing of drugs. Many generic manufacturers are based in India and most of them produce good quality products. One of them is Dr. Reddy’s Laboratories. Of the four generic manufacturers of Zomig two are based in India (Glenmark and Zydus), one in Taiwan (Impax) and one is based in the US (Mylan) but also has many manufacturing plants in India. An Israeli company Teva, the largest manufacturer of generics in the world is known for their high quality products and it also has plants in many countries, including India.

Once you find a product that works, stick with that generic manufacturer even if you have to switch pharmacy chains since the entire chain usually carries the same generic. The law requires that the name of the manufacturer is printed on the medicine bottle your receive from the pharmacy, so it is easy to find out who the manufacturer is.

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Triptans are the first line migraine drugs in pregnant women

Dr. Mauskop — Thu, 16 May 2013 02:31:42 +0000

Pregnant women are admonished not to take any medications while pregnant. Fortunately, two out of three women stop having migraines during pregnancy, especially during the second and third trimester. Unfortunately, one third of women continue having migraines and in some they get worse. Tylenol (acetaminophen), which is deemed to be the safest pain medicine in pregnancy is also the weakest pain killer and does nothing to relieve the agony of a migraine attack. Many obstetricians say that they are also “comfortable” giving drugs containing butalbital (a barbiturate) and caffeine along with acetaminophen (Fioricet) because these drugs have been around for many years. However, barbiturates are really not good for the developing brain while regular intake of caffeine can cause worsening of migraine headaches. Narcotic (opioid) analgesics are not exactly healthy either. Not taking any medications is also harmful to the mother and the fetus because severe pain causes serious distress to both and vomiting, which often accompanies migraines, can cause dehydration. Not treating migraine attacks may also lead to chronic migraines with pain present continuously. So, what is a pregnant woman to do?
At the recent annual meeting of the American Congress of Obstetricians and Gynecologists several doctors expressed their preference for the use of triptans in pregnant women. Sumatriptan (Imitrex) was first introduced 20 years ago and a registry of women who took sumatriptan during pregnancy suggests that this is a safe drug. Pregnancy registry for rizatriptan (Maxalt), which is the second triptan to come to the market 15 years ago, also suggests that it is a safe drug. Of course, it cannot be said that these drugs are proven to be safe for pregnant women because some yet undetected risk may still be present. However, compared to the alternatives and considering that triptans are much more effective, it is logical to recommend their use in pregnancy.
Besides treating an acute attack with triptans we always recommend preventive measures, such as magnesium supplementation (400 mg, on top of what is in a prenatal vitamin, which is usually only 100 mg), biofeedback, regular sleep, and exercise.
Preventive drugs that can cause major problems in the fetus and are contraindicated in pregnancy include divalproex (Depakote) and topiramate (Topamax). On the other hand, Botox is probably a safe preventive treatment in pregnant women suffering from chronic migraine headaches.

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Botox helps post-traumatic headaches in soldiers

Dr. Mauskop — Mon, 13 May 2013 14:40:23 +0000

Botox appears to be effective for the treatment of chronic post-traumatic headaches in service Members with a history of mild traumatic brain injury according to a recent report by Dr. Juanita Yerry and her colleagues at Ft. Bragg, NC. The researchers assessed the safety of onabotulinum toxin type A (Botox) in the preventive care of post traumatic headache. Headache is a common complication of mild traumatic brain injury in active duty service members. Migraine and chronic migraine type are the most common headache types. The approved use of Botox in chronic migraine made the doctors think that Botox might be safe and possibly effective in post-traumatic headaches with features of chronic migraines. They examined records of all patients treated with Botox for post-traumatic headache in the Concussion Care Clinic at Womack Army Medical Center, Ft. Bragg, NC between 2008 and 2012. They recorded patient demographics, prior history of headache, injury type, current headache type, time from injury to first injection, treatment techniques, number of treatments/treatment interval, side effects, reasons for discontinuation and Patient Global Evaluation of Change (PGEC). Out of 67 patients (66 male) who were treated 10% had prior history of headaches. Most common injuries were blast (46.3%), parachute jumps (14.9%) and motor vehicle accidents (11.9%). About 56% reported more than one headache type. Headache types included: chronic migraine (22.4%), episodic migraine (7.5%), chronic tension type (7.5%), hemicrania continua (7.5%), nummular (1.5%); mixed tension/chronic migraine (41.8%), and tension/migraine (7.5%). A very large percentage (75%) had a continuous headache. Reasons for discontinuing Botox treatment included ineffectiveness (44.8%), side effects (2.9%), or reinjury (1.5%). They were not able to follow-up with 22% patients of whom 73.3% reported being “much better”. Overall, 60% were better or much better, 4.5% were worse or much worse, and 33% reported no change. The researchers concluded that Botox appears to be safe and well tolerated in active duty service members treated for post-traumatic headaches.

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Not all narcotics are equally addictive

Dr. Mauskop — Wed, 08 May 2013 14:25:57 +0000

Abuse of prescription narcotic (opioid) drugs is growing at an alarming rate and they are responsible for tens of thousands of deaths due to overdose every year. While all such drugs can cause addiction, there appears to be a difference among these drugs. A study recently published in The Journal of Pain suggests that a new opioid pain killer, tapentadol (Nucynta) is less likely to cause addiction than oxycodone (Percocet, Percodan, Endocet). The study was conducted by the manufacturer of Nucynta, a subsidiary of Johnson & Johnson. The researchers looked at the risk of shopping behavior (going to more than one doctor to obtain prescriptions) in over 150,000 patients. People who were prescribed oxycodone were four times more likely to be doctor shoppers than those who were prescribed tapentadol. Also, 28% of those prescribed oxycodone were asking only for oxycodone, while only 0.6% of those prescribed tapentadole were asking for tapentadol. This means that of those prescribed tapentadol less than one percent were asking only for tapentadole and the rest asked for other narcotics. Tapentadol has another advantage in that it causes less nausea and constipation than other opioid drugs.

Abuse potential is also reduced by making the pill temper resistant. About two years ago Oxycontin, which is one of the most popular (and most abused) long-acting narcotic pain killers was reformulated to make it difficult to crush. Because Oxycontin is a long-acting drug and does not give a quick high, addicts usually crush the tablet and inject or snort it. The new formulation prevents it from being crushed and in the past two years the abuse (and the sales) of Oxycontin has dropped. The FDA recently denied permission to sell generic versions of Oxycontin because they did not have such temper-resistant properties.

Unlike with other types of pain, opioid drugs seem to be less effective in the treatment of migraine and other headaches. Headache patients often report little relief from these drugs, as well as side effects, such as nausea and sedation. Opioid analgesics, such as codeine, hydrocodone (Vicodin), oxycodone (Percocet), and other can actually make headache worse in some patients by causing rebound, or medication overuse headaches. However, there are exceptions to this rule and a very small number of our patients respond only to opioid drugs and a few are doing well with daily long-acting narcotics. To make sure these drugs are not being abused we carefully select and closely monitor such patients.

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Fear delays recovery in whiplash injuries

Dr. Mauskop — Sat, 04 May 2013 20:52:35 +0000

Fear and avoidance of activity may play a role in fostering disability in whiplash-associated disorders, according to a new study by University of Washington researchers published in the latest issue of journal Pain. This study examined the role of fear after whiplash and assessed the effectiveness of 3 treatments targeting fear. They evaluated 191 people still suffering from whiplash symptoms 3 months after the injury. Patients were assigned to one of the following three treatments: (1) informational booklet describing whiplash disorder and the importance of resuming activities, (2) informational booklet plus a discussions with clinicians reinforcing the booklet, and (3) informational booklet, plus a psychological technique called imaginal and direct exposure desensitization to feared activities. The second and the third group received three 2-hour treatment sessions. Those given psychological intervention reported significantly less post-treatment pain severity compared with those given a brochure or brochure and discussion. Reduction in fear was the most important predictor of improvement, followed by reductions in pain and depression. The authors concluded that the results highlight the importance of fear in individuals with persistent whiplash injury symptoms and suggest the importance of addressing fear through exposure therapy and educational interventions to improve function.

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Prophylactic migraine drugs are all equally mediocre

Dr. Mauskop — Wed, 01 May 2013 11:17:38 +0000

Preventive drugs for migraine headaches help less than half of the patients they are given to. There is no significant difference in effectiveness in these drugs. They reduce frequency of attacks by 50 percent, according to a review published in the recent issue of the Journal of General Internal Medicine.

Dr. Shamliyan from the University of Minnesota in Minneapolis and her colleagues conducted a literature review to identify high quality clinical trials of preventive drugs versus placebo.

Based on 215 published trials, the researchers found that all FDA-approved drugs, including topiramate (Topamax), divalproex (Depakote), timolol (Blocadren), propranolol (Inderal) and off-label medicines metoprolol (Toprol), atenolol (Tenormin), nadolol (Corgard), captopril (Capoten) and lisinopril (Zestril); and candesartan (Atacand) were effective in reducing monthly migraine frequency by 50 percent or more in 20% to 40% of patients. Topiramate, other off-label antiepileptics, and antidepressants had higher levels of side effects and were more likely to be stopped by patients because of side effects. While there were no significant differences in benefits between approved drugs, candesartan and other blood pressure drugs were the most effective and had fewest side effects for the prevention of episodic migraines.

The authors also noted that there was no evidence for long-term effects of drug treatments (that is trials lasting more than three months).

This review confirms my bias in favor of Botox injections over drugs. Botox helps not only 70% of chronic migraine patients, but in my anecdotal (but involving thousands of patients) experience it is equally effective for the prevention of frequent episodic migraines.

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Anxiety and depression are associated with various pains and migraines

Dr. Mauskop — Mon, 29 Apr 2013 02:22:40 +0000

It is a well established fact that migraine sufferers are 2-3 times more likely to develop anxiety and depression. The reverse is also true: if you suffer from anxiety and depression, you are 2-3 times more likely to develop migraine headaches. These associations are called comorbidities. Anxiety and depression are also comorbid with other pain syndromes. A group of Dutch researchers examined records of almost 3,000 patients with anxiety and depression to look for the presence of comorbid migraines and pain in the back, neck, face, abdomen, joints, and chest. All patients were interviewed twice, with a two year interval, and were asked if they had any of those pains in the preceding 6 months. Their results, published in The Journal of Pain, clearly show that having anxiety and depression increases the risk of developing migraines and other pain syndromes equally. So, this association is not specific to migraines, but applies to all pain syndromes. This means that anxiety and depression do not cause headaches and pain and the other way around. Most likely, one condition predisposes the sufferer to develop the other. It is also likely that shared genetic predisposition or the involvement of certain brain chemicals that are involved in both pain and depression, such as serotonin, adrenalin, and other, may be responsible for these associations.

Botox relieves myofascial (muscle) pain

Dr. Mauskop — Wed, 24 Apr 2013 17:28:35 +0000

Botox seems to help neck and upper back muscle pains, according to a recent study by UCLA doctors. We know that one of the actions of Botox is to relax muscles and it has been effective for the treatment of sciatic pain, according to a previous blinded study. Drs. Nicol and Ferrante at UCLA gave a single injection of Botox to 118 patients with neck and upper back pain. Six weeks later 54% of patients showed improvement. Then, 8 weeks later, half of the 54 responders were given again Botox and the other half placebo (saline injection). Those who received Botox did much better not only on pain scores, but also on quality of life measures. They also had a significant improvement in the number of headaches. This is not that surprising, since many of our patients report that their headaches begin with muscle spasm in the neck or upper back. It is very likely that giving more than one injection will lead to a greater improvement in a larger percentage of patients. In chronic migraine headache patients injecting Botox into 31 sites has been proven to be very effective.

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A new procedure for pseudotumor cerebri

Dr. Mauskop — Mon, 22 Apr 2013 12:01:11 +0000

A new treatment for pseudotumour cerebri was reported by a team of interventional neuroradiologists and neurosurgeons. Pseudotumour cerebri is a rare condition, which manifests itself by increased pressure in the head, leading to severe headaches, vision impairment and even complete loss of vision and brain damage. It affects more women than men and usually occurs without an obvious trigger, although pregnancy, obesity, and certain medications increase the risk of developing this condition. The diagnosis is made by performing a spinal tap (lumbar puncture) and measuring cerebrospinal fluid pressure. Typical MRI scan findings (narrowing of the ventricles – cerebrospinal fluid filled spaces in the brain) and finding of swollen optic nerves (papilledema)on eye exam confirm this diagnosis.

The new treatment is based on the theory that narrowing of a vein located at the back of the brain is the underlying cause, although this theory remains controversial. Narrowing of this vein is thought to reduce drainage of the cerebrospinal fluid from inside the brain, leading to build up of this fluid and increased pressure inside the skull. The usual treatments for pseudotumor include weight loss, medications that reduce pressure, such as acetazolamide (Diamox), and the surgical placement of a shunt to continuously drain spinal fluid from the brain, thus reducing the pressure.

The study, published in the online edition of the Journal of Neuro-Ophthalmology, shows that lowering pressure inside the vein alleviates the condition and improves vision. The doctors at Johns Hopkins used an advanced ultrasound scanner to thread an expandable metal stent through a vein in the groin, all the way to the transverse sinus, one of the main veins inside the skull draining fluid from the brain.

The study involved only 12 patients, but all of them had immediate relief of their headaches and 10 had lasting improvement. The researchers admitted that the efficacy of this treatment needs to be confirmed in a larger group of patients.

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