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

Questions from the clinic: ‘I’ve heard about injections for chronic migraine, and I’d like to ask you some questions about it’

Please note as per TGA guidelines we are not permitted to mention the name of the product discussed in this blog entry

Part 2

Q How soon might I see a benefit?

A Patients may take 4 weeks after the injections to notice benefit, although they may see improvement sooner. In some patients a benefit may not be seen until after their second injection series.

Q May I take other medications for headache while I’m receiving injection therapy?

A Yes. Prompt treatment of acute migraine headaches with appropriate medications and in a frequency that will not cause medication overuse headaches is advised. Your migraine specialist will provide you with an acute migraine treatment strategy. This will assist the injection therapy to achieve a remission of your chronic migraine back to the episodic form of that headache disorder.

Q I am thinking about trying for a pregnancy in the next few months, can I still commence injection therapy?

A No, injection therapy has not been tested in pregnancy and therefore should not be administered to pregnant woman or in women who may become pregnant in the 3 months after it is injected. It should also not be used when patients are breastfeeding.

Q What happens after the first set of injections?

A Afterwards patients are able to drive home and resume normal activities. Vigorous neck exercises, neck massage, and or physiotherapy are however discouraged for 24 hours after the procedure.

There is good evidence that when it works, injection therapy has a cumultative effect, with better and better response with each cycle administered every 3 months across a year.
However after 2 injection cycles, as per PBS criteria, if no improvement is noticed, the injections should be discontinued.

Q: My injection therapy for chronic migraines has been working well, but I’m worried that it will stop being effective, what are the chances of this happening?

A A study that sought to answer this question was recently published by Cernuda-Morolion et al in Cephalagia 2015, Vol 35 (10):864-868 titled ‘Long-term experience with (injection therapy) in the treatment of chronic migraine: What happens after one year?

• Only in around 1/10 patients did injection therapy lose their clinical efficacy after more than one year of treatment
• There was no failure after the third year of treatment
• In 43% of cases, injections can be delayed to every 4 months (16 weeks) after the first year of treatment

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

References:

Headache: The Journal of Head and Face Pain, 2014, American Headache Society, Tepper MD

Questions from the clinic: ‘I’ve heard about injection therapy for migraines, and I’d like to ask you some questions about it’

Please note as per TGA guidelines we are not permitted to mention the name of the product discussed in this blog entry

Part 1

Q  Should I consider injection therapy for my frequent migraines?

A  Yes, if you are over 18 years of age, not pregnant, breastfeeding or planning for a pregnancy in the next 3 months, and suffer from chronic migraine. You should also consider the therapy if at least 3 preventative medications provided from your doctor have resulted in limiting side effects or have been unable to provide you with significant benefit.
Chronic migraine is a disabling problem for 2% of the population, having an adverse impact upon an individuals quality of life, as well as their families. Injection therapy is the first approved intervention found to result in a significant improvement in this disorder.

Q How does a migraine specialist know that I am suffering from chronic migraine?

A  A migraine specialist will be assessing you for the diagnosis of migraine, and then for the frequency of headache and migraine events to determine if a diagnosis of chronic migraine can be made. A migraine headache is diagnosed when characteristic features are associated with your headaches, that being light and noise sensitivity, nausea, as well as pain that is moderate to severe in intensity.

Q What is the active ingredient in injection therapy?

A  The active ingredient is an injectable protein produced by a bacterium (Clostridium botulinum) that paralyzes muscles into which is in injected.

Q  Are the injections the same for every patient?

A  Yes, and the precise location and quantity of each injection has been tested extensively for safety and effectiveness in a wide variety of disorders.

Q What are the possible side effects?

A  Injection therapy is generally well tolerated. A brief, stinging sensation can be produced at each injection site. In a small percentage of patients, (3-9%), neck pain, headaches, heaviness of the brow and or eyelids can be experienced, however these are all temporary should they occur.

Q How does injection therapy work for migraines?

A  Injection therapy is believed to work for migraine by blocking pain signaling transmission between the head and neck and the central brain where migraine is generated.

Q Will injection therapy cure my migraines?

A  No, injection therapy is not a cure for migraines, it does however represent an effective preventative intervention in many migraine patients. When it works for chronic migraine, the results can be dramatic, not just in reducing headache days but with significant improvement in headache related quality of life assessments

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

References:

Headache: The Journal of Head and Face Pain, 2014, American Headache Society, Tepper MD

As with a variety of health issues, chronic migraine is best treated by preventing its occurrence in the first place. Once chronic migraine has developed, its successful treatment, with remission back to the episodic form, will require the expertise of a migraine specialist to achieve.

What are the risk factors for chronic migraine development?

• Increase in headache attack frequency
• Overuse of acute headache medications
• Obesity
• Disorders of mood (anxiety or depression)
• Insomnia, disrupted sleep

 What can you do to prevent chronic migraine?

• Patients with episodic migraine need to avoid completely the use of strong opioids such as Endone, Oxycontin, and or Pethidine.
• Many patients are also not aware that common over the counter medications such as Nurofen Plus, Panadeine, and Mersyndol, contain codeine, which is a weak, but potentially addictive opioid.
• If your headache frequency is increasing, seek review with a migraine specialist, do not wait until your headaches occur daily before you get help
• Treat headaches early and aggressively, your migraine specialist will be able to provide you with a plan for acute headache treatment
• The addition of a medication to prevent migraines may be required, and your migraine specialist can advise you of your available options.
• Begin and stick with a regular exercise plan
• If you are overweight/obese, commence a weight loss program
• Seek treatment for any co-existing disorder of mood or sleep

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

 References: Migraine ‘Chronification’: What you can do, Headache 2009, American Headache Society, Rothrock MD
Over the counter sale of codeine pain killers such as Nurofen Plus and Panadeine may end, April 2015, Sydney Morning Herald, Aisha Dow, Julia Medew

Questions from the clinic: When should I take my acute migraine medication?

Answer: As early as possible!

At our migraine clinic we have noticed a common issue amongst our patients- they don’t treat their migraines early! Instead they delay treating a headache because they ‘wait to see if it’s going to be a migraine’

At our migraine clinic we advise our patients that the key to effective management of an acute migraine attack is early recognition and treatment

Migraine patients often report that they suffer migraines and headaches, though most headaches experienced by a patient with migraine are in fact migraine headaches, and will respond to their usual acute migraine medication.

As a migraine evolves its responsiveness to treatment decreases. Medications developed specifically for acute migraine treatment, are far more effective if taken when the headache is still early, and mild to moderate in intensity, rather than later, when moderate to severe in intensity.

Delaying taking acute migraine medication risks not resolving the headache completely, and this can be linked to the early recurrence of further severe headaches!

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

References: Acute migraine treating early, Headache 2009, American Headache Society, Rothrock MD

Around 30-50% of migraine patients will sometimes experience dizziness, a sense of spinning, or feeling off balance with their headaches. Migraine specialists now call this vestibular migraine.

A frequent additional symptom is head motion intolerance, ie imbalance, and a sense of motion, often with nausea, aggravated or triggered by head movements.

Vertigo provoked by moving scenes such as traffic or movies, ie visually induced vertigo, can be another prominent feature of vestibular migraine.

Vertigo can precede headache, may begin with headache or may appear late in the headache phase. Many patients experience attacks both with and without headache. In some patients vertigo and headache never occur together, and this can make the diagnosis of vestibular migraine at times challenging.

Along with the vertigo, patients may experience light and noise sensitivity and or visual or other auras, and this can help the migraine specialist establish the link to migraines. Triggers for vestibular migraine attacks can also be similar to those seen in more typical migraine, for example, menstruation, lack of sleep, stress, specific foods, bright lights, strong smells or noise.

There are warning signs or red flags that vertigo is not part of a migraine, including new and sudden onset, sudden hearing loss, ear fullness, loss of balance alone, +/-weakness, and these suggest urgent evaluation for a non migraine disorder.

Otherwise, if a diagnosis of vestibular migraine has been established by a migraine specialist, standard migraine prevention and attack treatment strategies are typically prescribed, and these are frequently effective.

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

References:

Vestibular Migraine, Lempert MD et al, Seminars in Neurology 2013;33:212-218

Migraine associated Vertigo, Tepper MD, Headache 2015, American Headache Society

In the Migraine Specialist clinic we are often asked the following question: Does drinking coffee cause or cure my headaches?

The answer is not completely straightforward and there are a couple of things you need to know about the relationship between coffee and headaches because caffeine is a two-edged sword when it comes to headaches. It can lead to either generation or alleviation of headaches.

Caffeine has different effects with episodic intake versus regular exposure.

Regular use of caffeine leads to physical dependence, and abstinence can result in a withdrawal syndrome. This syndrome includes symptoms suggestive of migraine including severe headache, fatigue, nausea and vomiting.

The higher prevalence of migraine reported on weekend mornings has been partially attributed to the withdrawal effects of caffeine.

Regular caffeine consumption is associated with chronic migraine, the development of chronic daily headaches and analgesic overuse headaches. To reduce the risk of developing these conditions, patients prone to headaches should limit their caffeine exposures.

On the flip side of the equation, however, episodic caffeine intake, although in some individuals is capable of triggering a migraine, may prove to be an effective adjunct in treating acute migraine. Certainly, some of our patients are very surprised when we recommend their acute oral migraine medication be taken with a strong coffee!

During migraine attacks stomach emptying may be delayed, and oral medications are unable to be absorbed and exert their treatment effect. Caffeine can improve the stomach’s motility, and, as well as allowing for absorption of oral medications, may exert a direct pain-relieving effect itself.

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

References:

Caffeine and headaches, Shapiro, Neurol Sci (2007) 28:S179-S183

 The Truth About Triggers, Rothrock, Headache 2008 American Headache Society

“Does being overweight have anything to do with my chronic headaches?”

Normal weight people with migraine have around a 3% chance of developing chronic headaches in a year. If they are overweight, they have 3 times that chance. With obesity, the chance of chronic migraine increases 5 times.

Obesity has not been found to cause migraines, only to increase their frequency. Both conditions however are associated with the release of pain generating hormones, and perhaps there is an additive effect. Migraine has also been associated with an increased risk of heart attack and stroke, and this may relate to higher levels of insulin, glucose and cholesterol in migraine patients.

Keeping track of your weight is therefore important, and there are a few issues to consider:

• Several oral medications prescribed to treat migraine can be associated with weight gain, and its important to be aware of this. Certainly this is one of the benefits of injection therapy for migraine, as weight gain and or changes in appetite are not associated with this treatment.
•  Keep active, and in fact regular aerobic exercise has been shown to result in fewer headaches.
•  Make sure your doctor monitors your cardiovascular risks, controlling blood pressure, cholesterol, blood glucose and not smoking, are all important to lessen your risk of a heart attack or a stroke.

If you are overweight, addressing this issue, as part of your entire migraine treatment strategy can result in better health overall, with the added benefit of less headaches!

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

References: Headache: 2013 American Headache Society, Tepper MD

One question we are regularly asked at Migraine Specialist is whether perimenopause or menopause are connected and if menopause has an impact on the frequency and severity of headaches and migraines. We know that women are more likely to suffer from migraines and we know a lot of women in this demographic visit us at Migraine Specialist, so we wanted to share more information on this topic with our wider community.

“Does Perimenopause or Menopause have anything to do with my frequent headaches and migraines?” 

A number of our patients are women between the ages of 40-50 years old and many of them experience perimenopausal type symptoms including hot flushes, insomnia, night sweats, decreased libido and irritability. Many also experience an increased headache frequency during this time, so it’s no wonder they ask “is menopause and migraines connected?”

A study recently was undertaken to examine the relationship between headache frequency and menopausal transition in women with migraine. The study provided good evidence that high frequency headache is indeed increased during the perimenopausal period.

The identification of this increased risk during the menopausal transition is important, in that it suggests a need for effective migraine preventative treatment during this time of a woman’s life when they are also experiencing hormonal changes a during this stage of life. That’s where our team of specialists can help – if you are a woman who is suffering from regular headaches or migraines and at this stage of your life, get in touch with our team and we can provide some more information and steps to support your treatment.

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

References:

Menopause are associated with High Frequency Headache in Women with Migraine Prevalence and Prevention Study , Martin et al, Headache 2016; 56:292-305