Medications

13 February 2015

Whatever Happened to Levadex?

We’ve been talking about the new migraine drug, Levadex, since 2010. But it’s still not on the market. Will it ever be?

Levadex was still in the news last year, but under a brand new name. Semprana is the new name for Levadex, a new formulation of dihydroergotamine mesylate (DHE). It’s now owned by Allergan, the makers of Botox.

Semprana is an inhaled migraine abortive. It looks especially promising for nausea, and sensitivity to light and sound.

But last summer, Semprana was rejected yet again by the FDA in the United States. That’s the third time. The good news is that the rejection had nothing to do with whether or not Semprana works, or whether or not it’s safe. Instead, the FDA had technical concerns about the manufacturing and functioning of the device.

Semprana remains in Allergan’s pipeline, and is still looking like it could be a big player in the migraine market. But consumers probably won’t be seeing it in the local pharmacy until 2017.

6 February 2015

The Best Medication for Migraine? The AHS Reports

James Discoveries & Stats, Information, Medications 0

Last month the American Headache Society came out with a new report suggesting which drugs have the best evidence behind them when it comes to migraine. According to the trials, what works the best?

Best Meds 2015 This, of course, does not mean that these medications will work the best for you. There is a lot of variation within migraine, and your doctor will help you decide where to start.

However, if your doctor isn’t talking about some of the treatments at the top of the list, you should be asking some questions.

The full report can be found here: The Acute Treatment of Migraine in Adults: The American Headache Society Evidence Assessment of Migraine Pharmacotherapies. However, here is a summary of some of the authors’ findings.

The medications with the best evidence behind them included:

The Triptans: Certain specific triptan medications were mentioned, such as almotriptan, sumatriptan, and naratriptan
Butorphanol nasal spray
NSAIDs: aspirin, diclofenac, ibuprofen and naproxen
Acetaminophen, but only for “non-incapacitating attacks”
DHE
Acetaminophen/aspirin/caffeine combo
Sumatriptan/naproxen combo

Some of the medications that really don’t have good evidence behind them, or the evidence is conflicting at this time, include:

Lidocaine IV
Celecoxib
Hydrocortisone IV

This is only a portion of the list – most medications fall between these two extremes. Also, it’s important to note that the researchers noted actual dosages, which means of course that any particular medication may work better/worse at a different dosage, but it may not have been studied.

Also, remember that these are only “acute” medications – taken at the time of an attack – not preventatives.

The conclusion of the study offers an appropriate warning:

According to this systematic review of the literature and structured grading of the evidence strength, specific medications within the following classes are considered “effective” for the acute therapy of migraine: triptans, ergotamine derivatives, NSAIDs, opioids, and combination medications. Several other medications are considered “probably effective” or “possibly effective.” This evidence base for medication efficacy should be considered along with potential medication side effects, potential adverse events, patient-specific contraindications to use of a particular medication, and drug-to-drug interactions when deciding which medication to prescribe for acute therapy of a migraine attack.

22 January 2015

Amerge for Cluster Headaches

James Information, Medications 0

Is Amerge for cluster headaches an overlooked treatment?

Amerge or Naramig are brand names for naratriptan, another in the triptan class of medications which include sumatriptan and zolmitriptan. Triptans are commonly used for both cluster and migraine.

Triptan options Triptans were gradually introduced into the market starting in 1991 with sumatriptan. But this gradual release has perhaps caused some problems which are true for migraine patients but magnified when it comes to cluster.

Naturally, the first triptan to arrive has been studied the most. Maybe it’s more because of this and less because of its effectiveness that sumatriptan has become the go-to triptan for cluster.

Because cluster is so rare, and because of challenges in running clinical trials, it will be a long time, if ever, before we have good data on whether Amerge for cluster headaches, or another triptan, is the best option – and for what type of patient.

The other challenge is that the newer triptans are less likely to have better (faster) delivery methods – such as nasal sprays and injections.

Naratriptan has been used as an add-on to high dose verapamil treatment (Naratriptan in the preventive treatment of cluster headache.). This cluster case study in 2002 showed a 2.5 mg twice daily dose of naratriptan completely stopping cluster headache in a 36 year old male. And naratriptan is being used, though maybe not as much as it should be.

The best advice for doctors and patients is probably the advice that’s often given in the case of migraine. If one triptan doesn’t work at all, or not as well as you hoped, you may have much better success with another. Talk to your doctor about trying another option. Amerge may be one to try next.

For more on triptans, check out:

10 Triptan Facts You Need to Know Now (written primarily for migraine patients, but still has information relevant to cluster)
What is Triptan-Overuse Headache?

15 December 2014

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

James Discoveries & Stats, Medications, Treatments 1

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.

Thanks to:

8 December 2014

OptiNose for Migraine: Not Approved Yet

James Medications, News, Treatments 0

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.

OptiNose The 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: