This month the FDA in the USA approved the very first CGRP antagonist nasal spray, brand name Zavzpret. The drug is known as zavegepant. The new medication should be on the market as early as this July.
You may remember that the “gepant” medications, such as zavegepant, seem to be good abortives – taken during a migraine attack, they fight symptoms at the time (as opposed to preventatives, which of course prevent attacks).
People who would prefer to avoid injections and pills often go to nasal sprays. Many people like the speed of injections, but don’t like the injections themselves. And with migraine nausea, pills can be hard to take.
However, nasal sprays also tend to be very fast-acting. Zavzpret as a medication seems to be pretty fast-acting itself, which is good news for those who want to stop those migraine symptoms from escalating. The most recent study showed relief from pain as quickly as in 15 minutes.
Zavzpret is also very simple to use. It will probably be prescribed as one spray (into one nostril) of 10mg, once. That’s all.
Another advantage of Zaczpret is that there seem to be very few side effects. The most common (though still only a minority of patients experienced it) was a change in your taste – in other words, foods might taste a little funny. This was just temporary.
The World Journal of Otorhinolaryngology ? Head and Neck Surgery recently published a review of the link between migraine and tinnitus. It’s an extensive review, but here are a few things that stand out.
The link between migraine and tinnitus has been explored before. A large percentage of patients with tinnitus also experience migraine attacks. If you include hearing loss and all auditory symptoms, it may be that most migraine patients experience some kind of auditory symptom.
The authors of this review (from the University of California) were particularly interested in tinnitus that “fluctuated”.
As you probably know, tinnitus refers to hearing ringing or other noises in the ears. Sometimes this is “objective” – there is actually something making noise in you body, that your doctor can detect. But most often it’s “subjective” – only you can hear it. That doesn’t mean there’s no physical cause or trigger, simply that it can’t be detected by anyone else.
Tinnitus may be fairly steady, but often times it is temporary, or it fluctuates. This may be because of something you ate, the weather – or even a migraine attack. Tinnitus that fluctuates with headache of course suggests a connection, but sometimes the tinnitus and headache or migraine may have a common trigger – such as weather changes.
The authors suggest that both migraine and tinnitus may have some common treatment paths. Some of the most interesting ones:
Dehydration: Staying properly hydrated (and this means a proper balance of hydration and salt in the body) may decrease both migraine attacks and tinnitus.
General Health: Improving exercise and diet may help decrease both conditions.
Sleep Health: Sleep problems can be huge in both migraine and tinnitus. A sleep test and follow-up treatment is something to look into.
Supplements: The review briefly mentioned 400mg magnesium and 200mg vitamin B2 (riboflavin) twice daily. Both of these are well-known migraine fighters.
Medications: There are certain medications that may help with both conditions, such as nortriptyline and topiramate.
Once again, it’s important for your doctor to know if you’re suffering from migraine and tinnitus, because there may be treatments that will be a higher priority for you. Start by making sure you’re hydrated each day (check out the app for iOS – Waterlogged. There are many similar options.). Check your sleep satisfaction to see if treatment in that area would help. And consider supplements such as B2 and magnesium.
Also, talk to your doctor about medications. Some may help, but there are others which may make the problem worse.
The story of acetaminophen/paracetamol, commonly associated with the brand name Tylenol, is a strange one. A researcher studying treatments for worms requested one chemical and received the wrong one. The worms didn’t mind it, but it did seem to fight fever.
It was in the late 1800s that acetaminophen was first used to fight fever and pain in Germany. But it was never widely used until it came to market in the USA and the United Kingdom in the 1950s.
As might be expected, a drug to treat pain and/or fever quickly became popular. Not only by itself, but in combination with other medications under numerous brand names. Few medications are taken with as much frequency as this one.
As is the case with many drugs, we’re not really sure how it works. The most common theory today is that it blocks COX (cyclooxygenase) enzymes in the brain, thus keeping pain signals from being transmitted. Read more from Tufts University School of Medicine: How Does Acetaminophen Work?
Being so common, problems started to arise with overdoses. It’s easy to take too much, or to take two products that contain paracetamol without carefully checking the labels. (By the way, unlike some “painkillers”, taking more of this one doesn’t increase its power – so never take more than the recommended amount thinking it will help you more.)
The “good” news may be that this may not be your best choice for headaches after all. Sure, if it works for the occasional tension-type headache, there may be no reason to change. But if you’re popping a pill every month, or every week, it’s time to talk to your doctor. But when it comes to other headache conditions such as migraine, there are so many better options that you may want to avoid acetaminophen altogether. SeeIs Acetaminophen/Paracetamol Really “Ineffective”?
Recent studies remind us of some key issues that we’ve talked about before:
Even “safe” medications should be used rarely, if possible. They all have risks.
You are an individual, and you need to find what works for you.
Lifestyle, such as regular movement and what you eat, are still king, and can never be replaced by a pill.
Read labels.
Getting headaches on a regular basis? Talk to a specialist. There are probably better treatments than over-the-counter painkillers.
Paracetamol is a unique drug with a strange history. It has helped many, but as our knowledge continues to expand, we may find that it has had its day. This will be an interesting story to keep watching.
Lidocaine has been used for many years in migraine treatment. Emergency rooms have given it by IV. It’s been given through a tube up the nose directly to the nerves. It’s been used for SUNCT and SUNA (types of chronic headache).
Opinions about the pain-killing effects of lidocaine have been generally positive, though not always overwhelming compared to other options. But one thing that has intrigued researchers is that some patients seem to find that their headache attacks diminish in the weeks after the treatment (see for example Can this Procedure Teach Your Body to avoid Migraine?).
This recent study is positive on both counts. Records were pulled from 832 migraine patients who had received continuous multiday lidocaine infusions. The collection was narrowed down to 609 patients, 81.1% female and 18.9% male. Patients generally did experience pain relief – going from 7/10 on the pain scale to 1/10 by the time they left the hospital. 87.8% responded well to treatment.
A couple of things to note here. First, the lidocaine IV was only one of several treatments that these patients received. So this is not proof that the lidocaine, at least by itself, was decreasing the pain. But from what doctors have seen in the past, it seems to be one useful tool.
Second, remember that these were patients with serious migraine. Hospitalized over several days, these were not mild attacks, and were often part of a chronic pattern.
So with that in mind, let’s see what happened after they left the hospital. Follow-up happened between 25 and 65 days later.
At follow-up, 43% were practically pain-free still. Headache days decreased by about 16% on average.
These may not seem like incredible results, but for patients with such serious migraine, it’s a hopeful sign that lidocaine may be a way to help break the cycle for some.
The researchers write:
Continuous lidocaine infusions were associated with improvement in acute pain in most patients and a decrease in both average pain and the number of headache days per month that extended out to 1 month. … Lidocaine may be a viable treatment option for patients with refractory chronic migraine who have failed other treatments. A prospective, randomized, double-blind trial is needed to confirm these results.
Lidocaine, although a treatment that’s been around a long time, is still one to watch. As we learn how to use it better, it may turn out to be a major way to stop migraine attacks that just won’t stop otherwise.
It’s about time to have an update on QULIPTA, otherwise known as atogepant, a newer migraine preventative.
You may remember that we were talking about atogepant back in 2020. At a time when many medications were coming out as injections, atogepant was a bit of a breath of fresh air. A preventative, taken orally, and only taken once a day (10, 30 or 60mg), with or without food. Much more convenient even than many other oral preventatives.
Atogepant was approved by the FDA in 2021, but studies continue. QULIPTA came up at the June 2022 American Headache Society 64th Annual Scientific Meeting a number of times, and we’re learning more about it as it begins to be used more in the general population.
For example, it was found that some patients seem to lose weight when taking atogepant. It’s a minority, but still a significant number. Not only were patients less likely to gain weight, some actually lost weight taking the medication. Something to watch.
It was confirmed once again that you can take atogepant with or without food. The difference seems to be negligible.
It seems that although many patients find their symptoms diminishing in the first month of treatment, others do need to wait 2 or even 3 months before atogepant works for them. And so far, patients taking the preventative for a year seem to still benefit (we’ll keep watching this – remember, the medication is very new!).
A patient who took the COVID-19 mRNA vaccine experienced continuous migraine visual aura, and was successfully treated using atogepant. This may be a useful treatment for migraine symptoms after vaccination, another one to watch.
More studies have been done on the overall safety of QULIPTA. So far, the news is good – it seems to be generally safe. However, as with any medication, it is very important to tell your doctor about any supplements, medications, vitamins, and so on, that you may be taking. This may affect your dosage.
