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A Visit to My Headache Specialist: Migranal, Seroquel, Biofeedback & Headache Management

Another visit to my headache specialist, another round of medications and therapies. This is the first time I don’t have any anticipatory excitement that one (or some) will help. It’s not that I don’t think there’s a chance, I’m just too tired to get caught up in what ifs.

The prescriptions I left with are for Migranal, an abortive, and Seroquel, a preventive. I’ve never tried Migranal as on-the-spot abortive. I did use it when a three-week intensive treatment of injectable DHE caused muscle pain. (DHE and Migranal are essentially the same drug, just in different delivery forms.) That three-week treatment was cut short after I failed to respond even the tiniest bit.

Seroquel has been on my mind since reading this success story. I know what works for one person doesn’t always work for another, but I needed to ask. Since I’ve tried multiple meds in all the classes of drugs used for headache with no success, my doctor and I decided it was worth a shot. It can be sedating, but I have to wonder if being sedated with less headache would be better than the exhaustion that accompanies a migraine. (I need to read the full side effect profile before I fill the prescription.)

Biofeedback and headache management therapy are the other two treatments I’m going to try. That’s right, I have never tried biofeedback. I feel like an impostor writing a headache blog without trying it. I’ll be able to shed my shame soon.

Even though I don’t really know what it is, headache management is what I’m most excited about. Apparently I will learn tricks to help when I have a bad headache, like massage and neck exercises.

As I write this, my head is bad so my outlook is bleak. Whenever I have a low migraine, low pain, high energy stretch, like I did last week, I return to “normal” with a thud. Having had a total of three good weeks in the last two months, I now believe I’ll have more migraine-light days in the future. But I quickly grow impatient for the next time to arrive.

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Migraine Treatment News

Here’s the roundup of migraine treatments. Other news posts I’m working on are about presentations at the International Headache Society’s conference (including cluster headache news), depression and chronic pain.

Migraine Patients Who Take Triptans Report Greater Satisfaction Than Patients Taking Barbiturates or Opioids
Survey: Migraine Patients Taking Potentially Addictive Barbiturate or Opioid
Medications Not Approved By FDA as Migraine Treatments

The survey found that patients taking triptans are significantly more likely than those taking barbiturates or opioids to report that their medication works well at relieving migraine symptoms, with sixty percent of triptan patients reporting that it describes their medication “extremely” or “very” well to say it relieves their migraines symptoms completely compared with 42 percent of patients taking barbiturates and opioids.

Patients taking opioids and barbiturates for their migraines also reported a lower quality of life than patients taking triptans, according to the survey. Patients taking these drugs were twice as likely as patients on triptans to say that migraines “always” limited their ability to exercise or play sports (35% vs. 14%), engage in sexual activity (33% vs. 17%), drive a car (28% vs. 14%), spend time with family and friends (28% vs. 8%) or simply get out of the house (33% vs. 15%).

Though many patients are prescribed barbiturates and opioids for their migraines, the majority indicated that they prefer their migraine medication to be FDA approved for the disease, not addictive and have few side effects. Seven out of ten patients (72%) surveyed said it’s “extremely” or “very” important that their prescription medications not be addictive, and eight out of ten patients (79%) said it’s “extremely”
or “very” important that their prescription medication have only minor side effects. Sixty-five percent said it’s important that their migraine medication be approved by the FDA to treat the disease.

Frova for Menstrual Migraine
Endo’s Menstrual Migraine Treatment Better Than Placebo in Study

Endo Pharmaceuticals said that its Frova 2.5mg tablets reduced the frequency and severity of difficult-to-treat menstrual migraine in women when used as a six-day preventative regimen.

Predicting Botox ‘s Effectiveness
Cutaneous Allodynia Predicts Response to Botulinum Toxin Type A in Migraine Patients

Botulinum toxin type A has been reported to be effective in preventing migraine attacks in some patients but not in others.

[R]esearchers found that patients with cutaneous allodynia had experienced significant reductions (P <.01) in migraine frequency and number of headache days in response to botulinum toxin type A, whereas patients without cutaneous allodynia had no such improvement in symptoms.

[I]nvestigators concluded that cutaneous allodynia could be used to predict which migraine patients are likely to respond to prophylactic therapy with botulinum toxin.

DHE Relieves Skin Sensitivity (Allodynia)
Migraine With Skin Sensitivity Eased By Older Drug

Dihydroergotamine or DHE, an established drug for migraine, works well even when the attack is accompanied by super-sensitivity to touch or heat and cold, according to researchers.

Many migraine sufferers get relief from the newer drugs known as triptans, but these are less effective when people also have heightened skin sensitivity. This condition, called cutaneous allodynia, makes even a light touch to the face or neck feel painful.

“Unlike triptans, DHE works in the presence of allodynia, any time in the migraine attack,” lead investigator Dr. Stephen D. Silberstein told Reuters Health.

Migraine Preventives
Migraines: Symptoms Disappear With The Right Prevention

According to Greek researchers, migraine sufferers can eliminate symptoms altogether if they take higher doses of anti-migraine medicine for a longer period of time than is now customary. Another team of researchers has found that certain psychopharmaceuticals could serve as a new therapy option for persistent chronic headaches.

“In treating migraines, optimizing the effect of already available agents is at least as important a task as developing new substances.”

I’m a little wary of this article, but wanted you to know about it. Take it with a grain of salt.

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Magnesium & Migraine

By Christina Peterson, MD

Should You Be Taking Magnesium?
Two doubleblind studies have shown that magnesium supplementation may reduce the frequency of migraine. In research studies, we have found that magnesium levels affect serotonin receptors, and also have an effect on nitric oxide synthesis and release, as well as on NMDA receptors—all brain structures and chemicals suspected to be important in migraine. In small studies, both migraine and cluster headache patients have responded acutely to intravenous magnesium. In a larger double-blind controlled study, the treatment group, receiving 600mg of magnesium for a 12 week period, experienced a 41.6% reduction in headaches as compared to only 15.8% reduction in migraine headaches in the placebo group.

What Does Magnesium Do?
It is responsible for over 300 essential metabolic reactions in the body. It is required for synthesizing proteins in the mitochondria, and for generating energy in most of the body’s basic cellular reactions. It is necessary for several steps in the synthesis of DNA and RNA. Magnesium is also present in a number of other important enzymes. As important as it is intracellularly, 60% of the body’s magnesium is present in bone, and 27% in muscle.

Magnesium Supplements
If you decide to take supplemental magnesium, start at 400-500 mg/day in divided doses. The limiting factor for most people is diarrhea. If you are on a migraine preventative medication that is constipating, like amitriptyline or verapamil, this might be a plus.

WARNING: If you have heart disease or kidney disease, or are prone to kidney stones, talk to your doctor before starting on calcium and/or magnesium.

To be metabolized effectively, magnesium must be taken with calcium. The amount of calcium should be no more than double the amount of magnesium— this is the ratio commonly recommended for women. Men may require less calcium, and sometimes take a ratio of calcium-magnesium that is equivalent mg/mg.

Many people take in only 60-70% of the recommended daily allowance in the first place, and then things like stress and caffeine can deplete that further throughout the day. Migraine sufferers have been found to have a relative magnesium deficiency in their bloodstream between migraine attacks, and intracellular magnesium levels drop even further during a migraine attack.

Magnesium oxide, magnesium citrate, and magnesium sulfate are bioavailable — look for mixed salts of these forms, or magnesium gluconate, which is ionized, and is biologically active; if you develop diarrhea from those forms of magnesium, look for chelated magnesium.

Magnesium carbonate dissolved in CO2- rich water is 30% more bioavailable than magnesium found in foods or in pill-format.

Foods Rich in Magnesium

  • Peanuts*
  • Almonds*
  • Brown rice
  • Hazel nuts*
  • Blackstrap molasses
  • Bananas*
  • Beans
  • Tofu*
  • Soy beans*
  • Avocado*
  • Broccoli
  • Spinach
  • Swiss chard
  • Tomato paste
  • Sweet potato
  • Pumpkin seeds
  • Peanut butter*
  • Chocolate*
  • Cocoa powder*
  • Succotash
  • Cooked artichoke
  • Black-eyed peas
  • Whole-grain cereals
  • Cooked okra
  • Beet greens
  • Acorn squash
  • Chickpeas
  • Split peas
  • Lentils
  • Kiwi fruit*
  • Apricots
  • Baked potato
  • Raisins
  • Yogurt*
  • Milk

*these can be migraine triggers for some people

Magnesium-Drug Interactions

  • Digoxin – Decreased absorption due to magnesium
  • Nitrofurantoin – Decreased absorption due to magnesium
  • Anti-malarials – Decreased absorption due to magnesium
  • May interfere with quinolone or tetracycline antibiotics
  • May interfere with anticoagulants
  • Diuretics such as furosemide (Lasix) or hydrochlorothiazide can result in magnesium depletion
  • Iron supplements may interfere with magnesium supplement absorption

This article appeared in the April/May 2006 of the Headquarters Migraine Management newsletter, Dr. Peterson’s bimonthly newsletter on migraine awareness and education. If you’re not signed up to receive this electronic newsletter, you’re missing out!

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Migraine Stories: Laura’s Success

Seroquel has proven a successful headache preventive for Laura of Headaches and Movies. After a year of being totally incapacitated, she is fully functional — working, moving out of her parents’ house and going out with her “awesome roommate.”

As always, everyone’s body is different. What works for one person may not work for others. Even if Seroquel isn’t the drug for you, it’s heartening to know that there are (many) success stories. Laura wrote, “. . . I couldn’t imagine my life being better right now. There’s nothing overwhelmingly fantastic happening, things are good. And life being good is a damned nice change.” Her post shares her story in more depth.

Congratulations, Laura! May life continue to delight you.

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Possibilities for a Better Headache Preventive

Our options for headache preventives suck. Yeah, some work for some people and it is a matter of trial and error based on each person’s needs, but there aren’t any consistently effective drugs available. All in My Head author Paula Kamen shares this disconcerting information:

“…I heard a variety of doctors clearly make an assertion again about the inadequacy of the currently available preventives. ‘Interestingly, a majority of commonly used [preventives] have little evidence of efficacy. In contrast, almost all options have well documented adverse effects, often leading to a discontinuation of preventive therapy,’ read a summary in the program book leading to the presentation of Dr. David W. Dodick, the well-respected director of the Headache Program at the Mayo Clinic branch in Scottsdale, Arizona. This time the assertion was backed up by the citation of many studies, including a major federally sponsored one for 1999 done at Duke University.” (Page 285)

If current understandings and expectations of a new compound, called tonabersat, play out, we may get a preventive of our very own. Tonabersat is the first in a class of compounds called “gap junction blockers.” (“Gap junction blockers” refers to the overall class or type of compound, just like “antidepressants” refers to a group of different drugs.) Targeting a different type of brain action than other drugs that are used as preventives, gap junction blockers are thought to be a breakthrough for headache prevention.

Depending on how you look at it, there’s either a lot of promise or a lot of hype for tonabersat. Some of the soundbites include:

  • “Tonabersat is an extremely interesting compound with a novel and very specific mechanism of action which means it is likely to be effective in prophylaxis of migraine.” (According to a past president of the International Headache Society who is working with the clinical trials)
  • “Given the clear demonstration of clinical activity with tonabersat in previous migraine studies, we anticipate it showing real benefit.” (Said the CEO of Minster Pharmaceuticals, the company that bought the rights to tonabersat and will develop the drug)
  • Tonabersat “represent[s] the first major advance in the treatment of migraine since the introduction of Imigran [Imitrex in the US].” (From GlaxoSmithKline, who identified the initial compound and is expected to market the drug if it is approved)

I am wearily intrigued. A good headache preventive would be invaluable, but there are so many obstacles left that I can’t get excited yet. Trials are in the early stages. Results aren’t expected for a couple years and FDA approval won’t come until long after that. The drug may turn out to not be effective or may have unbearable side effects. Or it could work great and makes us all happy. Or be somewhere in between.

To learn more about the study, see the press release or the blurb in the Cambridge Evening News. For more about tonabersat, see Minster Phamaceuticals‘ product overview and company profile.