Congratulations to our esteemed colleague, stem cell researcher Professor Alan Mackay-Sim, the 2017 Australian of the year award recipient.

Neurologist, Dr Nicole Limberg from Migraine Specialist was privileged to be able to assist with his research, providing SSEP measurements for his paper, ‘Autologous olfactory ensheathing cell transplantation in human paraplegia: a 3-year clinical trial’ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2525447/

His work is truly an amazing achievement, with potential implications for a variety of neurological conditions, and Dr Limberg is very proud to have been of assistance.

Calcitonin Gene Related Peptide Targeted Therapy for Migraine

There is an emerging class of medications for migraine treatment, targeting the calcitonin gene related peptide (CGRP). These drugs are likely to become available in the next 2-3 years. They appear to be effective and specific medications, blocking the pain pathway most likely to result in migraines. They are referred to as CGRP blocking medications.

CGRP is a substance present in many organs throughout the body, including the brain. When it is released around nerves of the head, CGRP causes blood vessels to expand and also brings about inflammation. Both of these factors probably cause the pain of migraine.

CGRP medications can be divided into 2 distinct groups, the larger sized group, called monoclonal antibodies (Mabs), that cannot cross the barrier into the brain, and the small sized compounds that are able to cross through the blood into the brain and other organs. One of the small molecules, sometimes called ‘gepants,’ was unfortunately found to cause liver problems in some patients, and this has limited the further development of these agents.

The Mab medications though are promising as they have been shown to decrease the frequency of migraine in many patients by around 50%, though in some fortunate, around 1 in 6, patients, the migraines seemed to go away, at least for 3 months. Thus far, these drugs have shown no major side effects when given to patients, although potential problems of blocking CGRP on a long term basis, if any, are not yet known, and further observation will be required.

Reference:

Calcitonin Gene-Related Peptide Targeted Therapy for Migraine, Tepper, Headache. The Journal of Head and Face Pain 2016.

Note: Information on this site is not a substitute for professional medical advice. 

Today we post our response to a question that gets asked frequently by patients in our clinic.

Injection therapy has shown efficacy in chronic migraine, though the way it works to achieve this effect remains unknown. Recent studies have however provided some intriguing insights as to the potential mechanism of action of the drug.

Migraine is presumed to commence with a cortical spreading depression (CSD) phenomenon, which then activates the trigeminovascular system (TVS). The release of neuropeptides, mainly Calcitonin gene-related peptide (CGRP), is then thought to occur from nerve terminals of blood vessels around the brain. The local release of these neuropeptides causes these vessels to widen and for inflammation to occur, resulting in the typical, throbbing, migraine pain.

Persistent headache with a watery, red eye? Read on

Hemicrania continua (HC) is a rare headache disorder, more common in females, usually beginning in adulthood. It always involves head pain on one side only, although rarely it can switch sides.

The pain typically involves the forehead, temple, eye and occipital regions. The pain is present continuously, with frequent worsening, daily or several times a week.

Exacerbations of the pain are associated with tearing, redness of the eye, eyelid drooping, sweating or a runny nose or congestion on the side of the headache, and these are referred to as cranial ‘autonomic’ features.

Patients with HC may become restless and unable to sit still or lie down. The pain when severe can have migraine features such as light and or noise sensitivity, as well as nausea.

There are a few conditions that can mimic HC and an MRI and opthalmological review is essential before the diagnosis can be made. In addition, a diagnostic criterion for HC is an absolute response to Indomethacin (Indocid). This is an anti-inflammatory medication, similar to ibuprofen, however the drug is unique in that it is the only medication that can stop HC.

Most patients can tolerate the drug, however in around 20% of patients side effects limit its regular usage, in particular gastrointestinal side effects, such as gastric ulcers. There are alternative medications that have been trialled with effect, in this scenario, including injection therapy, as can be used with chronic migraines.

HC is a type of primary headache, which your headache specialist will be able to diagnose and treat. In general, it is able to be managed, with patients able to lead normal lives, once an effective regimen has been established, tolerated, and then taken regularly.

Note: Information on this site is not a substitute for professional medical advice.

References:

Hemicrania Continua, Headache, The Journal of Head and Face Pain, Tepper, 2015
Hemicrania Continua Responsive to ‘Injection therapy’ A Case Report, Khalil et al, Headache 2013;53:831-833

Please note the name of the medication has been removed as per TGA guidelines, and is referred to as ‘injection therapy’

The American Academy of Neurology has released an updated guideline, the first since 2008, based on a review of scientific studies of injection therapy as treatment for chronic migraine.

‘Injection therapy has been established as safe and effective for reducing the number of headaches in chronic migraine and should be offered as a treatment option to patients’ with this condition, ‘to increase the number of headache free days ‘.  The therapy additionally ‘should be considered to reduce headache impact on health related quality of life’ in chronic migraine.

Note: Information on this site is not a substitute for professional medical advice.

References: Practice guideline update summary: Injection therapy for the treatment of blepharospasm, cervical dystonia, adult spasticity and headache, Simpson et al, Neurology 2016;86:1-9

It is well known that chronic migraine, tension headaches and temporomandibular dysfunction (TMD) can be associated. This is not unexpected as these diseases involve the same painful stimuli system, via the Trigeminal Nerve. The name ‘trigeminal’ is derived from the fact that each nerve has 3 major branches.

At migraine specialist the concept of ‘stratified’ care to the treatment of an acute attack of migraine is applied. This treatment approach recognises the evolving nature of a migraine attack. In last weeks blog we included a graph of the evolution of an attack of migraine https://migrainespecialist.com.au/blog/5-steps-successful-acute-migraine-management/

For the migraine patient it is best to have a few therapies available that they can select from for acute migraine treatment, depending on the stage of their migraine event.

1/ something for early/mild headache;

2/ something for migraines that have escalated despite 1/, or that have escalated rapidly to become moderate to severe events;

3/ a rescue therapy if 2/ fails

With this graded approach, patients typically find themselves far more capable of managing their acute migraine attacks

Note: Information on this site is not a substitute for professional medical advice.

References:

Acute Migraine Treatment: ‘Stratified’ Care, Headache 2012, Rothrock

Learning to understand your migraines and the best way to manage them effectively is essential for the migraine patient to achieve results.

 1/Set a Goal for your treatment:  A reasonable goal is to be free of migraine within 2 hours, with no return of migraine for at least 24 hours, though this may not be able to be achieved every time.

2/Recognize that Migraine is a Process: The figure below depicts the different phases of a migraine attack. The ideal time to treat is when the headache is early and mild in intensity.

Our staff respond to many phone, email and other enquiries daily about the service we provide.

Every week we meet to collate these queries, discuss further, and as a team we consider, ‘How can we continue to improve the outcomes for our patients?’ Potential patients ask, ‘How can your clinic help me?, and

GPs ask, ‘Why should I refer my patient to your clinic?’

Today we try to answer these questions in our blog. As per TGA guidelines we are unable to mention the medication referred to as ‘injection therapy’

Q: What do you do at Migraine Specialist?

A: At Migraine Specialist we specialise in the management of Chronic Migraine. Each of our patients has had a unique migraine treatment journey, and we approach each individual case with this in mind.

Q: What is the goal of Migraine Specialist?

Chronic migraine is common, affecting approximately 3% of the population, yet it is our concern that awareness of the condition is low, and that a significant number of patients are not achieving an effective management strategy to improve their debilitating condition. Our goal is to increase awareness of the condition of chronic migraine, as well as to provide an approved treatment for sufferers.

Q What is a successful outcome for me, the patient?

A successful outcome for you, the patient, (and for us at migraine specialist!) is the effective treatment of chronic migraine, achieving remission back to the episodic form of the condition. For many patients with chronic migraine, this is the state they recall, at times several years prior, when relatively infrequent, treatable events were occurring.

Q I am a GP, and I’ve heard about injection therapy for chronic migraines, but I’m still not sure. Why should I refer my patients for this therapy?

 As medical specialists, we understand the scientific skepticism attached to any ‘new therapy’. It is worth noting however that this therapy has been the subject of several well conducted trials, as well as ongoing clinical reviews, with the following outcomes achieved:

• It is effective for chronic migraine, with a 70% response rate after 3 injection cycles ¹
• A significant reduction in severe migraine events is seen in treatment responders, with a 90% reduction in emergency department visits ²
• Significant improvements in Headache Related Quality of Life assessments can be achieved ³
• The therapy is provided every 12 weeks, as opposed to requiring daily treatment compliance
• It is well tolerated, with no definitive, serious adverse effects reported in chronic migraine

Note: Information of this site is not a substitute for professional medical advice.

References

1. Percent of patients with chronic migraine who responded per ‘injection therapy’ treatment cycle, Silberstein et al PREEMPT JNNP; 86:996-1001
2. Experience with ‘injection therapy’ with chronic refractory migraine: focus on severe attacks, Oterino etc et al, J Headache Pain 2011 Apr;12(2): 235-238
3. ‘Injection therapy’ for Treatment of Chronic Migraine, Aurora et al, Headache 2011; 51(9);1358-1373

A multitude of triggers can set off an attack in migraine patients. Examples of such triggers include foods such as wine, chocolate and caffeine, stress or the sudden lack of it, ie ‘let down’ stress, changes in sleep patterns, and hormonal fluctuations at various times in a women’s life. A number of migraine patients will also report that weather change can be causative.

Migraineurs who are influenced by the weather can be sensitive to temperature and humidity. Many migraine patients will also state that changes in barometric pressure will trigger their migraines.

Humans can be exposed to low atmospheric pressure during air travel, and some migraine patients, in particular cluster migraine patients do relate this as a trigger for their events. It is true though that flying is associated with several other potential triggers (eg poor air circulation, uncomfortable positions, poor food, alcohol, change in time zones and insufficient sleep).

A small sample of 7 patients who stated that they suffered weather related migraine exacerbations were recently asked to participate in an experiment.

They were instructed to follow weather forecasts, and if a low pressure system was predicted, they were asked to start a long acting headache medication either the evening or morning before the forecasted pressure drop.

Though it was a very small sample, 83% of the patients had a positive response to the therapy and this suggests that migraine medications, taken in preparation for a low pressure weather event, may be a worthwhile treatment strategy in susceptible patients.

 Note: Information on this site is not a substitute for professional medical advice.

References:

 Does Low Atmospheric Pressure Independently Trigger Migraine? Bolay; Rapoport, Headache 2011; 51:1426-143
The Effect of Weather on Headache Prince et al, Headache 2004;44:596-602
Long Acting Triptans and Weather Related Migraines, Jacobs, Headache 2014