Injection therapy (PBS-Approved Nerve Blocking Therapy)

If you suffer from chronic migraines, are over 18 years of age, not pregnant, breastfeeding or planning for a pregnancy in the next 3 months you should consider injection therapy. You should also consider the therapy if at least 3 preventative medications provided from your doctor have limiting side effects or have been unable to provide you with significant benefit.

Injection therapy is generally well tolerated. The precise location and quantity of each injection has been tested extensively for safety and effectiveness. 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.

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

Injection therapy is not a cure for migraines, it does however represent an effective preventative intervention in many migraine patients.

Injection therapy (PBS-Approved Nerve Blocking Therapy) has been 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 cycles1
  • A significant reduction in severe migraine events is seen in treatment responders, with a 90% reduction in emergency department visits2
  • Significant improvements in headache related disability, resulting in significantly improved functioning, vitality and overall Headache related Quality of Life Assessments can be achieved3
  • Compliance with migraine prophylactic medications is a major issue, with the need to consume an oral medication every day, or sometimes 2 to 3 times per day. Convenience is superior in this regard with injection therapy, with the injection cycles administered every 12 weeks
  • Patients receiving injection therapy also had significantly fewer intakes of triptans (acute therapy), than did placebo groups

Injection therapy (CGRP blocking therapy)

New, first of their kind injectable treatments for the prevention of migraine in adults have been approved in Australia. The medications are calcitonin gene related peptide (CGRP) monoclonal antibody therapies.

CGRP is a neurotransmitter associated with the development of migraine. CGRP levels have been shown to increase significantly during a migraine and return to normal with migraine relief. This new injectable treatment works specifically by blocking the activity of the CGRP molecule.

The drugs have been evaluated for prevention of both chronic and episodic migraine in randomised, multi-centre, placebo-controlled, double blind studies. For many patients, the medications were shown to reduce the number of monthly migraine days versus placebo and in some patients cut monthly migraine days by 50% or more. 4,5,6,7,8

Improvements were seen within four weeks of commencing treatment with the medications. The drugs are also efficacious in patients who have previously failed prophylactic migraine treatment due to lack of efficacy or intolerance and in patients with a history of medication overuse.

A favourable adverse effect profile was seen from the pivotal trials, with no major side effects apparent. A few mild adverse events for the therapy have been reported however, including injection site reactions, constipation, muscle spasms and itchy skin.

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.

References

  1. Stephen D Silberstein, David W Dodick, Sheena K Aurora, Hans-Christoph Diener, Ronald E DeGryse, Richard B Lipton, Catherine C Turkel, (2015), Per cent of patients with chronic migraine who responded per on a botulinumtoxin  A treatment cycle: PREEMPT. J Neurol Neurosurg Psychiatry. Sep; 86(9): 996–1001.
  2. Oterino,1 C. Ramón,2 and J. Pascual (2011) Experience with onabotulinumtoxinA (BOTOX) in chronic refractory migraine: focus on severe attacks. J Headache Pain Apr;12(2):235-238
  3. Aurora SK, Dodick DW, Turkel CC, DeGryse RE, Silberstein SD, Lipton RB, Diener HC, Brin MF, on behalf of PREEMPT 1 Chronic Migraine Study Group (2010) OnabotulinumtoxinA for treatment of chronic migraine: results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 1 trial. Cephalalgia 30:793–803,
  4. Goadsby PJ, Reuter U, Hallström Y, Broessner G, Bonner JH, Zhang F, Sapra S, Picard H, Mikol DD, Lenz RA (2017) A controlled trial of erenumab for episodic migraine. N Engl J Med 377:2123–2132
  5. Tepper S, Ashina M, Reuter U, Brandes JL, Doležil D, Silberstein S, Winner P, Leonardi D, Mikol D, Lenz R (2017) Safety and efficacy of erenumab for preventive treatment of chronic migraine: a randomised, double-blind, placebo-controlled phase 2 trial. Lancet Neurol 16:425–434
  6. Stauffer VL, Dodick DW, Zhang Q, Carter JN, Ailani J, Conley RR (2018) Evaluation of galcanezumab for the prevention of episodic migraine: the EVOLVE-1 randomized clinical trial. JAMA Neurol 75:1080–1088
  7. Silberstein SD, Dodick DW, Bigal ME, Yeung PP, Goadsby PJ, Blankenbiller T, Grozinski-Wolff M, Yang R, Ma Y, Aycardi E (2017) Fremanezumab for the preventive treatment of chronic migraine. N Engl J Med 377:2113–2122
  8. Detke HC, Goadsby PJ, Wang S, Friedman DI, Selzler KJ, Aurora SK (2018) Galcanezumab in chronic migraine: the randomized, double-blind, placebo-controlled REGAIN study. Neurology. 91:e2211–e2221

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    Streamlined Assessment Headache Clinic.
    No referral required for our Migraine Specialist GP!

      Specialists in Headaches and Migraines led by Neurologists

      1300 MYMIGRAINE
      (1300 696 447)
      07 3831 1611

      Email us

      Privacy Policy
      Cancellation Policy

      Address

      St Andrew’s Place Level 2 Suite 312, 33 North Street Spring Hill 4000

      Business Hours

      Monday – Thursday 8.30am – 4pm
      Friday 9.30am -2.30pm
      Saturday, Sunday: Closed

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