Doctors, News & Research, Treatment

More Migraine and Headache Hope: 2014 American Headache Society Symposium

Energizing and encouraging are the words I’d use to describe the American Headache Society’s symposium last week/weekend. The opening remarks on Thursday morning actually made me cry. After the AHS president, Dr. Lawrence Newman, shared his heartfelt frustrations with migraine treatment and gave an impassioned plea for the 36 Million Migraine campaign, the room went dark. Dr. Newman then asked everyone to stand up with their cell phones lit to “shine a light on migraine_and_headache_hopemigraine.” This picture from the AHS Twitter feed shows a small portion of the room in this powerful moment.

The strength of the moment was reinforced when the first presenter of the day, Dr. Dawn Buse, asked everyone in the audience with migraine to stand. Three-quarters of the room stood. She then asked everyone who had a loved one with migraine to stand. I don’t believe anyone in the room remained seated.

“These people care,” I thought so many times throughout the conference. I saw so many doctors, physician assistants, nurse practitioners, nurses and psychologists who are passionate and enthusiastic about headache medicine. They are frustrated about lack of funding and the stigma of headache and migraine, but they care deeply about and are dedicated to their patients. They are excited – ahem, cautiously optimistic – about the CGRP drugs that are in development for migraine as well as the neuromodulation treatments that are on the horizon (like transcranial magnetic stimulation and vagal nerve stimulation, both of which are noninvasive and should be available to patients soon).

This is the third year I’ve attended this particular conference and the fourth headache conference I’ve been to. The energy felt different. Maybe it was because I felt better and was able to engage more, but the enthusiasm and optimism seemed stronger than I’ve noticed before. Even more encouraging was the number of people new to headache medicine, mostly fellows in their early days of specialization, who attended the conference.

Yes, research for migraine and all headache disorders is underfunded. Yes, the arsenal of treatments is still nebulous and it’s hard to pin down what might help any individual patient. Yes, the stigma is still enormous. Yes, there is still a small portion of patients for whom it is difficult to find the right treatment. But the field is making progress and it’s being led by enthused and engaged providers who truly care for patients. The number of academic headache centers is on the rise, as is the number of fellows being trained in headache medicine each year.

I was already full of hope about the future of migraine treatment. This conference reinforced that my migraine and headache hope is well-placed. The tide is turning. It’s one of the many things I’m giving thanks for this week.

Want even more hope? Watch this interview with headache specialist and researcher Peter Goadsby. It’s well worth your eight minutes. (Many thanks to  Timothy for sending me this.)

Chronic Migraine, News & Research, Treatment

Predicting Botox Response for Chronic Migraine

When a patient asks if Botox will help them, the usual response is along the lines of, “Quite possibly, but you’ll have to try it to find out.” A patient’s blood levels of calcitonin gene-related peptide (CGRP) could predict whether a person with chronic migraine will respond to Botox, according to a study published in the journal Headache‘s June edition.

Researchers believe that a patient’s CGRP levels could predict whether Botox will be effective with 95% accuracy. In their study of 81 chronic migraineurs, those who had a CGRP level above a certain threshold were 28 times more likely to respond to Botox than those with CGRP levels below that threshold. (If CGRP sounds familiar, it’s probably because the research findings on migraine prevention drugs that made the news this spring are CGRP antibodies.) This is only one study and it was small. More studies will need to investigate and confirm a connection between Botox response and CGRP before doctors will begin checking CGRP levels before giving a patient Botox.

In the meantime, if you’re looking to figure out if Botox will help you, something called pain directionality is the best current predictor. Pain directionality is whether your pain feels like it is exploding, imploding or ocular. People with imploding or ocular pain are more likely to find relief from Botox than those with exploding pain.

Multiple studies have explored the connection between pain directionality and Botox response; here’s one you can read for free. However, headache specialist Alexander Mauskop warns that pain directionality “is not a very reliable predictor because some people have difficulty categorizing their pain in that way and because even if they do describe it clearly one way or another, this predictor is far from 100% accurate.”

Meds & Supplements, News & Research, Treatment

CGRP Receptor Antagonist a Promising New Migraine Abortive Drug

Calcitonin gene-related peptide (CGRP) receptor antagonist MK-0974 holds promise as a migraine abortive, according to Phase II study results that will be presented at the American Headache Society‘s annual meeting this week.

The drug works by blocking CGRP, a brain chemical that is important for transmitting pain signals during a migraine. It does not appear to contrict blood vessels, as triptans do, so people who can’t use triptans may be able to use MK-0974 as an abortive. Researchers hope that it will have fewer side effects and safety concerns than triptans do.

The American Headache Society’s press release on the study follows.

New Migraine Drug Holds Promise for Headache Sufferers: First Class of Migraine Medication Since the Triptans

CHICAGO – An innovative drug appears to treat migraines in a majority of people, potentially ushering in a new era for the treatment of the painful and disabling headaches, suggests early research being presented at the 49th Annual Scientific Meeting of the American Headache Society.

The study is the first presentation of a drug called MK-0974, which belongs to a potential new class of drugs, known as calcitonin gene-related peptide (CGRP) receptor antagonists.

Fifteen years ago, the advent of triptan medication revolutionized migraine treatment by stopping the headaches and related symptoms, rather than just providing pain relief. However, triptans don’t work for about a third of the estimated 28 million people with migraines and because they constrict blood vessels, they cannot be used in patients who have had a heart attack or stroke and should be used with caution by those who are at risk.

“The real excitement is that this drug has a different mechanism of action from the triptans, and the hope is that it will have fewer side effects and safety concerns,” said Alan M. Rapoport, M.D., clinical professor of neurology at the David Geffen School of Medicine at UCLA, in Los Angeles, and a co-author of a study on the drug being presented at the Society’s meeting.

The new drug works by blocking CGRP, a brain chemical that is important for transmitting pain signals during a migraine attack. Unlike the triptans, research has shown that the new drug does not appear to constrict blood vessels.

“Because we know that the CGRP level is elevated during a migraine attack, and that if you give CGRP intravenously, you can cause a migraine-like headache, we’ve been studying what would happen if you block the CGRP,” said Tony Ho, M.D., senior director of clinical neuroscience at Merck & Co., Whitehouse Station, N.J. “Our hope is that this drug potentially can have a significant impact for migraine patients as an additional treatment choice.”

The new drug has not been approved by the Food and Drug Administration (FDA). Results from the Phase II study being presented at the Society meeting are an early step in the development process.

The randomized, double-blind, placebo-controlled study tested safety and effectiveness of MK-0974 and involved a total of 330 people who suffered one to six migraines a month. Study patients kept a diary to assess: pain relief two hours after taking the medication, pain freedom two hours after taking the medication, and freedom from pain 24 hours later.

More than two-thirds (68 percent) of those who took the 300 mg dose of the new drug had pain relief two hours after the dose, compared to 69.5 percent of those who took the FDA approved triptan called rizatriptan and 46 percent who took a placebo, or dummy pill. Nearly half (45.2 percent) of those who took the new drug were free of pain after two hours, compared to 33.4 percent who took rizatriptan [Maxalt] and 14.3 percent who took the placebo.

More than a third (39.6 percent) were free of pain 24 hours after taking the new drug, compared to 18.4 percent who took rizatriptan and 11 percent who took the placebo. Common side effects included nausea, dizziness and sleepiness.

“These early results are very promising,” said Dr. Ho. “There’s potential for the new drug to be superior to the triptans 24 hours after the medication is taken, but this needs to be confirmed in a larger trial.”

“There’s good reason to believe that at least some people would respond to this drug, even if they did not respond to the triptans,” said Dr. Rapoport, who also is the cofounder and director emeritus of The New England Center for Headache, in Stamford, Conn. “Also, additional data suggest that this drug gets into the blood stream fairly quickly and may stay in the blood stream longer than several of the triptans.”

In addition to Drs. Rapoport and Ho, other authors of the paper being presented at the meeting are: Lisa Mannix, M.D., Xiaoyin Fan, Ph.D., Chris Assaid, Ph.D., Christine Furtek, M.S. and Chris Jones, M.S.