Headache Expert Question and Answer
Wednesday, June 10, 2009
Triptans and Headache
Q: Do triptans cause rebound headaches? Will there be a generic for Amerge coming out soon? I take 3-5 Amerge tablets a week to manage my headaches.
A: Amerge belongs to a family of medications called triptans, which includes Imitrex (sumatriptan), Zomig (zolmitriptan), Maxalt (rizatriptan), Relpax (eletriptan), Axert (almotriptan), and Frova (frovatriptan). Imitrex was the first triptan medication available in the United States and it is the first to be available in a generic version. Imitrex’s legal patent protection expired approximately one year ago and shortly thereafter generic sumatriptan received the Food and Drug Administration’s approval.
The other triptans have at least several years of patent protection remaining, thus generic versions of these drugs cannot be currently produced. It is difficult to predict if any pharmaceutical manufacturer will decided to produce a generic triptan in the future.
Richard Wenzel, Pharm.D.
Diamond Inpatient Headache Unit
Chicago, IL
Headache Prevention Medications
Q: Are there any new headache prevention medicines available?
A: Nothing FDA approved since Topamax, Depakote, and two old beta-blockers. We hope to have some new ones in the next couple of years that will be developed only for migraine, not just taken from another use.
Mark Green, M.D.
Columbia Univ. College of Physicians
New York, NY
Migraine with Lower Extremity and Neck Pain
Q: I have had migraines since childhood. I am now in my 40's. A large percentage of my migraines are accompanied by inflammation in my lower extremities and neck, which is unrelieved with the use of
anti-inflammatory such as Mobic or Arthrotec. I am unable to take triptans, due to a diagnosis of Prinz-Metal angina and a heart attack in 2005. My question is two fold.
1. Is there per event medication that is not a triptan?
2. Is the lower extremity and neck swelling common and is there treatment?
A: As you know, you cannot use triptans because of your angina. The same is true of ergot-related medications and Midrin. You will need to be treated with painkillers, rather than the more specific medications for migraine. If they are not working well, preventive drugs might be used to reduce the frequency of attacks, even if it is not high, which also can make the acute drugs work better when you take them.
Lower extremity and neck swelling are not expected symptoms of migraine, so I cannot advise you of their cause or significance.
Mark Green, M.D.
Columbia Univ. College of Physicians
New York, NY
Hemicrania Continua
Q: What are treatments for hemicrania continua? I was taking Maxalt five to six days a week for several years, but my internist said that was too much and sent me to a neurologist.
The neurologist diagnosed the condition and is determined that I should take Indomethacin daily as a preventive. This medicine is causing severe stomach pain and swelling (so bad I could barely wear my shoes). Although the Indomethacin works most of the time, I have to take 150 mg of Zantac along with the Indomethacin and a prescription diuretic to alleviate the swelling. Surely, there must be another solution. I fear I will soon have to be treated for bleeding ulcers because of the treatment for the headaches. The Maxalt worked and did not cause me problems like the Indomethacin.
Within the past year I have developed hypothyroidism (Hashimoto’s disease) and am being treated for that as well. It has had no effect, good or bad, on my headaches.
A: Only Indomethacin has been shown to have consistent effects in treatment of hemicrania continua. There are only case reports of other treatments being successful. In many cases a low dose of Indomethacin is successful. The stomach complaints may occur with any of the NSAIDS and therefore appropriate precautions are mandatory. These should be discussed with your doctor as well. A
headache specialist may be needed to explore other therapeutic options.
Fred Freitag, D.O.
Diamond Headache Clinic
Chicago, IL