Topiramate + Nortriptyline (and another reason why treatment is not simple)

We’ve talked about nortriptyline, an antidepressant commonly prescribed for chronic pain, and topiramate, an anticonvulsant often used for migraine in particular, in the past. As you can see from the comments people leave here, both have been a wonderful help – or haven’t been so great – depending on the patient.

It’s not unusual for someone to try one or the other, discover that they’re still having migraine attacks, and drop the medication permanently. But that may not always be the best option.

A study published in the Journal of Headache and Pain in 2010 tested both of these medications together as a migraine treatment.

Researchers started with patients that had experienced less than 50% reduction in symptoms with either topiramate (Topamax) or nortriptyline after trying either one for eight weeks. 78.3% of the patients improved more when taking both together than when taking just one.

It is not unusual for a combination of treatments to be better – sometimes drastically better – than one or the other. This is just another example.

When your doctor suggests you retry something you’ve already tried – but this time with something else, whether it be a supplement or drug or other type of treatment, don’t brush the idea aside quickly (even if the drug didn’t work in the past at all).

On the other hand, be very cautious if you have experienced significant side effects in the past. For example, when it comes to topiramate watch out for heart palpitations or chest pain, visual changes, weakness, confusion, or a loss of appetite. For nortriptyline, common things to watch for are depression, trouble breathing, seizures, fever, fatigue or weakness.

And remember, never change your dosage without checking with your doctor.

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What is Retinal Migraine?

What exactly is retinal migraine? Do I have it, or could it be another disease?
What is Retinal Migraine
Over the past year, our article from 2009 about retinal migraine (5 Signs You have Retinal Migraine) has become the most popular article at Headache and Migraine News. But almost six years later, it’s time to revisit the discussion.

There is a lot of confusion over just what retinal migraine is, and that confusion is making it difficult to find proper treatment.

First, retinal migraine is a type of migraine with aura. There are various different types of migraine with aura, and different treatments are commonly used depending on which type you have.

There are various types of “aura”, some visual but some involving muscle weakness or difficulty speaking, for example. Retinal migraine used to be in a category by itself, but it is now categorized along with other aura types. In fact, more specifically, it is considered migraine with typical aura.

Symptoms of Retinal Migraine

Retinal migraine symptoms must be temporary, must involve vision, must be in one eye, must be repeated, and must NOT be associated with a disorder other than migraine.

Visual symptoms will vary. You might have an area of vision blocked out, or you may go blind in one eye. Or, there may be visual patterns and flashes.

Typically, the aura spreads gradually over a few minutes, and lasts an hour or less. Usually (but not necessarily) the aura will be followed by a headache.

The important thing to remember here is that retinal migraine is still something pretty specific. If your symptoms are in both eyes, for example, you do not have retinal migraine.

Important: It May Not Be Migraine

It is absolutely critical to have a doctor examine you if you think you may have retinal migraine. There could be other causes of these symptoms.

For example, loss of vision in one eye could be a sign of a stroke. It could be a sign of carotid artery disease, in which arteries supplying blood to the brain are blocked. Needless to say, this could be very serious.

Aura symptoms could also be a sign of traumatic brain injury. A brain tumour may also lead to similar symptoms.

Some people still think of “retinal migraine” as a common, benign disorder. But a careful examination and proper treatment (whether it’s retinal migraine or not) is critical.

The diagnostic criteria above is based on The International Classification of Headache Disorders, 3rd edition (beta version) (pdf)

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OptiNose for Migraine: Not Approved Yet

Last month the FDA announced that they would not (yet) approve a new migraine nasal spray, known as AVP-825 from OptiNose.

We’ve talked about this new delivery system for sumatriptan in the past (see OptiNose: In Search of a Better Nasal Spray). AVP-825 is a unique delivery system that delivers the medication (sumatriptan powder) quickly an effectively. For reasons of economy and health, it’s important to get all of the medication where it needs to go in your body as soon as possible.

OptiNoseThe phase III trials demonstrated that the medication and delivery system work, providing relief as early as 15-30 minutes after use, with most patients finding relief and nearly 20% completely free of migraine symptoms at 1 hour.

So what was the problem? Why did the FDA reject the medication?

“Human factors”. In other words, is the treatment easy enough to use so that us humans won’t mess it up.

Hopefully this will be a simple question to answer. Avanir Pharmaceuticals Inc. will be conducting a new trial with real humans, and hopes to respond to the FDA before the middle of next year.

For more information:

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The “Revolution” in Migraine Treatment (Dr. Peter Goadsby)

Last month the American Headache Society had their annual symposium in Arizona, USA. There was a lot of discussion about the new treatments coming down the pipe to fight migraine.

Dr. Peter Goadsby from the University of California did a brief interview which you can see here. But here is a quick summary of some of the things that he said. It’s worth while taking a look, because Dr. Goadsby did give an excellent summary about some of the new migraine treatments that are now being tested.

What follows is a summary of the interview…

The Problem

Today we have various treatments for migraine, most of which were not developed specifically for migraine. We’re not sure why many of them work, and patients must struggle with a number of side effects. “It’s a really awful mishmash of things that we have to offer.”

What’s Coming

There are some very exciting treatments that are being developed. The two that the interview focused on are related to CGRP (calcitonin gene-related peptide neurotransmitter).

Now the exciting thing about both of these is that they are working well in various trials. In fact, some people taking these are going a long time with no migraine attacks whatsoever.

How does this work?

The treatments use monoclonal antibodies directed against the CGRP. (Note: these are antibodies created in the lab for a specific purpose. Monoclonal antibodies are also being used in cancer treatment.)

One question is just how to best deliver the antibodies to have the maximum effect.

A big question is – why do these medications work so well (“spectacularly well”, said Dr. Goadsby more than once) for certain patients?  If we can figure that out, we could “deliver personalized, highly effective treatments that are well tolerated to a group of people who are otherwise horribly disabled“.

Dr. Goadsby thinks that the clue will probably be found in a genetic marker.  If we can find better personalized treatments, we will help patients, doctors, and society as a whole.

When is it going to happen?

Dr. Goadsby was reluctant to make a prediction, but he finally said,“I’m going to predict that in five years or so we will be using these medicines in clinical practice and they will revolutionize practice.”

Click the image below to go to the interview.

Dr. Goadsby Migraine Interview

via The Daily Headache

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More trailers from “Out of My Head”

Recently, The Migraine Project ran a successful Kickstarter campaign to raise money for their documentary, “Out of My Head”.  Below is the trailer that was used for the campaign.  To find out more, there’s another trailer on the Migraine Project page here (be sure to check that one out).

It looks like the film is scheduled to come out by January 2016.

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