Migraine Medications Explained: Abortive, Preventive, and CGRP Drugs with Dr. Hossein Ansari

00:03 – Announcer: Welcome to the Headache 360 Podcast, a place to listen and learn about the diagnosis and treatment of chronic headache and migraine pain. Because information can be the best medicine.

00:22 – Dr. Adam Lowenstein: Hi, and welcome to the Headache 360 Podcast. I am your host, Dr. Adam Lowenstein, and we have a fantastic repeat guest today, Dr. Hossein Ansari, who is the head of the Headache Clinic at the University of California, San Diego. And this is our second, hopefully in a series with Dr.

00:45 – Dr. Adam Lowenstein: Ansari, but you can refer to our first podcast with him for his outstandingly extensive degrees and education. And actually, let me say again, Dr. Ansari, thanks for joining us.

01:03 – Dr. Hossein Ansari: Thank you very much, Dr. Lowenstein. Thank you for having me again, and hopefully this series of podcasts can continue because I believe it’s very important for education of the patient with headache, and particularly migraine.

01:19 – Dr. Adam Lowenstein: Yeah, we’ve been getting a lot of great feedback, and actually your previous podcast is so far the most listened-to and most downloaded one that we’ve had, so thanks for that. I also wanted to say, which we haven’t talked about, that just looking online, your reviews

01:42 – Dr. Adam Lowenstein: are outstanding. That’s pretty rare, because when people come to me for migraine surgery, they’re usually complaining about their previous care. But there are so many comments saying, ‘Fabulous doctor,’ ‘Very professional,’ and ‘He listens to all of my concerns.’ I think that if everybody was as good a

02:06 – Dr. Adam Lowenstein: physician as you seem to be, I think we’d have a much better situation with migraines in general.

02:14 – Dr. Hossein Ansari: Thank you very much. It’s interesting you’re telling me that because I never actually look at my reviews online. I don’t want them to give me bias, and if even one out of a hundred patients is not happy and writes something, I don’t want to dwell on that.

02:34 – Dr. Adam Lowenstein: It hurts, it’s nice to see the good stuff. It hurts when you see it. It hurts, you know.

02:43 – Dr. Hossein Ansari: Okay.

02:44 – Dr. Adam Lowenstein: So that’s why I’m glad. Both of us seem to have a very high general level of reviews, so that’s great. But what we’re going to talk about today is medications, right?

03:01 – Dr. Hossein Ansari: Yes, yes. We decided to talk about medication because that’s one of the biggest questions that we always get. Let’s start with this. When I go to different conferences, meetings, or lectures, one thing they always ask me is, ‘What is your go-to medication for migraine? What do you use?’ This question doesn’t have one answer

03:23 – Dr. Hossein Ansari: because we don’t have any single go-to medication for migraine. Each patient with headache and migraine is different. Again, I’m emphasizing here the difference between headache and migraine. Today we are talking just about migraine. We know migraine can be both overdiagnosed and

03:44 – Dr. Hossein Ansari: underdiagnosed. That is very important to know. But again, that’s a totally different podcast that we could spend at least an hour going over. Let’s assume that the patient has a diagnosis of what we call migraine. One thing that we need to do before we start somebody on

04:04 – Dr. Hossein Ansari: medication for migraine to make sure patients headache and migraine is a pure migraine. There is no other big comorbidity that we need to fix or address before jump to the medication. one of the main reasons that the medication treatment failed in the migraine because of probably lack of the time for.

04:26 – Dr. Hossein Ansari: most of the physicians. When the pay physician sees the patient with migraine, they prescribe medication right away without looking at the entire picture. So that is very important. So lifestyle, lifestyle change and patients basically other comorbidities, it plays important role in terms of.

04:46 – Dr. Hossein Ansari: considering what we need to know and what even what medication we need to prescribe. Because sometimes we use when we prescribe medication for migraine, we basically use aside effect of the medication as a benefit for that particular patient. And say, for example, patient with migraine also had anxiety.

05:09 – Dr. Hossein Ansari: and depression, which we know are major comorbidities with migraine. About 60 to 70 percent of patients with migraine also have comorbid anxiety and/or depression. So for a particular patient, it’s very reasonable to use one of those antidepressants that is approved for migraine to

05:29 – Dr. Hossein Ansari: kill two birds with one stone, right?

05:31 – Dr. Adam Lowenstein: So can I just ask two questions real quick? This may be out of both of our purviews, but what comes first, the chicken or the egg? Does the depression predate the migraines, or do people become anxious and depressed because they have pain?

05:50 – Dr. Hossein Ansari: I think both, because there have actually been a lot of studies done. Again, this is a whole separate podcast. One thing is very obvious and common sense: if you have a lot of headaches, you will be depressed, right? If you have headaches and cannot do your daily activities or hobbies, you will be sad.

06:11 – Dr. Hossein Ansari: And then that negative cycle continues. That is for sure. But also it has been shown that the patient had history or basically the predisposition for depression and anxiety used to get more migraine. Interesting. Both is happening. But very, very, very common comorbidity.

06:29 – Dr. Adam Lowenstein: And then I just want to get to something that you may be getting to eventually. Until recently, there weren’t really any medications developed specifically as migraine preventives. We found that medications developed for other purposes also helped migraines, and that’s why they were used.

06:50 – Dr. Adam Lowenstein: Is that a fair statement?

06:58 – Dr. Hossein Ansari: Exactly. We didn’t have migraine-specific preventive treatments, and we’re going to talk about that when we discuss the different classes of preventive treatment.

07:07 – Dr. Adam Lowenstein: Okay, so I’m sorry to interrupt you, then keep on going.

07:10 – Dr. Hossein Ansari: Sure. My emphasis is on lifestyle. Make sure the patient does not have any important factor in his or her lifestyle that can trigger migraine. For example, if you have a patient with migraine who is drinking a lot of Diet Coke – two or three Diet Cokes a day – we know artificial sweeteners can be a trigger for migraine.

07:32 – Dr. Hossein Ansari: If someone is drinking two or three Diet Cokes a day, artificial sweeteners can be a migraine trigger. If the patient keeps consuming diet drinks or other artificially sweetened products, they may be adding fuel to the migraine. No matter what medication you give, the chance of response may be lower.

07:54 – Dr. Hossein Ansari: So you need to understand the patient’s diet and what he or she eats. All of these factors are important, just as medication is important. Some of our colleagues in headache medicine focus extensively on lifestyle and diet.

08:17 – Dr. Hossein Ansari: Lifestyle, diet, and those areas can be a subspecialty focus. It’s very important. A patient with migraine should also have regular exercise. We recommend 30 to 60 minutes of moderate-intensity exercise five times a week.

08:39 – Dr. Hossein Ansari: That is treatment, and it can be as important as taking medication. You cannot separate lifestyle and activity from medication. What activity is helpful and what may be harmful is another discussion – we have a lot of podcasts to do here.

09:02 – Dr. Hossein Ansari: Now let’s go back to migraine treatment. We are considering a patient with a clear migraine diagnosis. You’ve addressed lifestyle and potential triggers, and now you want to use medication. Migraine medications can be divided into two classes.

09:23 – Dr. Hossein Ansari: One is called abortive or acute medication, which I’m going to call abortive from now on. The second is preventive or prophylactic medication, which I’m going to call preventive in this podcast.

09:47 – Dr. Hossein Ansari: Abortive treatment is medication the patient takes when a migraine is beginning. The sooner you take it, the better. That is different from many other pain situations. For example, with foot or knee pain, a patient may be told not to take pain medication until the pain reaches four or

10:10 – Dr. Hossein Ansari: five. With migraine, it’s the opposite: take the medication early. If a patient has aura, they may take it during that phase, but most patients do not have aura. As soon as they feel the headache coming, when the pain is at one or two, they take the headache medication.

10:32 – Dr. Hossein Ansari: And that’s why we call it headache rather than simply head pain. We prefer to use migraine-specific medication for migraine headache rather than relying only on general pain medication.

10:54 – Dr. Hossein Ansari: headache. So abortive treatment is needed for all of the migraine patients. Any patient with migraine needs to have abortive treatment. Period. Okay. But preventive treatment or prophylactic, which is the daily medication, is for some percentage of the patients.

11:15 – Dr. Hossein Ansari: Who needs preventive treatment? Generally, patients who get more than a certain number of headaches per month. The guideline we use says that if a patient with migraine has more than five attacks per month – more than about one per week – that patient should be considered for preventive treatment.

11:36 – Dr. Hossein Ansari: We also use other tools when deciding about prevention. There are migraine questionnaires that serve as measurement tools. One is called MIDAS and another is HIT-6. These help show how much headache affects the patient’s life.

11:57 – Dr. Hossein Ansari: If the score is higher, the headache is affecting the patient’s life more, and preventive treatment may be appropriate. As a general concept, if a patient is using abortive treatment more than once per week, preventive treatment should be discussed.

12:18 – Dr. Hossein Ansari: And so let’s go back to abortive treatment. Abortive treatment for migraine could be some simple analgesics: Tylenol or acetaminophen, ibuprofen, naproxen, and diclofenac. These are simple analgesic medications. Some are prescription, like diclofenac, and some are

12:39 – Dr. Hossein Ansari: available over the counter, like ibuprofen. If a patient’s migraine is infrequent and responds to these simple analgesics, that’s fine. If the patient takes ibuprofen or Tylenol only a few days per month and it works, that’s fine.

13:00 – Dr. Hossein Ansari: But if the patient is taking an abortive medication more than once per week – then two or three times per week – that patient also needs a discussion about preventive treatment. This is where over-the-counter medications can become confusing.

13:20 – Dr. Hossein Ansari: Patients may not keep track of how many doses they take per week or month, and that can become an issue. Some over-the-counter combination medications can easily contribute to rebound headache, or medication-overuse headache, such as Excedrin.

13:43 – Dr. Hossein Ansari: Excedrin is a medication that I generally do not recommend for my patients because it’s easy to overuse without realizing how much you’re taking.

13:58 – Dr. Adam Lowenstein: Okay, yeah, you mentioned that on our last podcast as well.

14:01 – Dr. Hossein Ansari: Yes, exactly. It is very important to make sure that if the patient is taking over-the-counter medication, there are limitations. So we have the simple analgesics, but when it comes to prescription medication, the gold-standard abortive treatment for migraine is triptan medication.

14:21 – Dr. Hossein Ansari: Sumatriptan is the oldest triptan and has been on the market since 1991. After that, six other triptans came to the market. Rizatriptan, or Maxalt, for example, is a common one; eletriptan, or Relpax; zolmitriptan, or Zomig; naratriptan, or Amerge; and frovatriptan, or Frova.

14:45 – Dr. Hossein Ansari: These are other triptans that we have on the market and that are FDA-approved for migraine. Imitrex is sumatriptan, yes – the oldest one, basically. All triptans come in oral form, and some also have injectable and nasal-spray forms.

15:06 – Dr. Hossein Ansari: Some triptans also come as orally disintegrating tablets, such as Maxalt. These are gold-standard abortive treatments for migraine. When we teach residents, we emphasize that migraine patients should have a triptan as part of their treatment plan when appropriate.

15:29 – Dr. Hossein Ansari: Rather than relying only on over-the-counter pain pills such as ibuprofen, use a migraine-specific medication such as Imitrex, Maxalt, or another triptan when appropriate. It’s important for migraine patients to discuss a triptan prescription with their physician.

15:50 – Dr. Hossein Ansari: There is a small percentage of patients who cannot take triptans because of a clear contraindication, such as coronary artery disease or a history of stroke. Fortunately, most migraine patients are younger and do not have those conditions.

16:12 – Dr. Hossein Ansari: So for most migraine patients, triptans can be considered unless there is a clear contraindication.

16:34 – Dr. Adam Lowenstein: Can I ask a couple of quick questions? We know that many preventive medications were originally brought to market for other conditions. Were triptans also used for something else before we realized they were helpful for migraine?

16:56 – Dr. Hossein Ansari: No. Triptans were actually developed specifically for migraine.

16:59 – Dr. Adam Lowenstein: Oh, triptans were made for migraines?

17:02 – Dr. Hossein Ansari: Yes, purely for migraine. The preventive treatments are the medications that were originally made for something else. That’s why we talk about two major revolutions in migraine treatment: triptans in the 1990s, and more recently CGRP therapies. We had migraine-specific abortive treatments, but

17:22 – Dr. Hossein Ansari: we did not have migraine-specific preventive treatment.

17:28 – Dr. Adam Lowenstein: Got it. Okay, and then my other question is I have a patient who I fixed the other day and I operated on. but prior to coming to me, they had been told that they could only take their tryptanone time a week. And they and this was from a rather.

17:53 – Dr. Adam Lowenstein: prominent neurologist in denver, and she had said that you should you can only take the triptan one time a week, and so one of their biggest complaints was you had to pick and choose which migraine that week they wanted to treat with tryptan. So it can you overuse triptans?

18:13 – Dr. Adam Lowenstein: What are the risks with that?

18:15 – Dr. Hossein Ansari: Actually, that was my next topic: how much abortive treatment can be taken. Abortive treatment means as-needed treatment. It is not something to take continuously.

18:36 – Dr. Hossein Ansari: For example, a patient may say, ‘I’m taking Excedrin daily to prevent headaches.’ Excedrin is not a preventive; it is an abortive, as-needed medication. We cannot take abortive treatments beyond a certain number of days per month.

18:58 – Dr. Hossein Ansari: And that certain number of days per month is different for each class of medication. The safest class in terms of not causing rebound headache, or medication-overuse headache, is non-steroidal medication – NSAIDs such as ibuprofen and naproxen. There’s one medication in that class called diclofenac

19:18 – Dr. Hossein Ansari: potassium. Diclofenac comes in two different salts, sodium and potassium. Diclofenac potassium has very strong evidence within that class, and that’s why the powder form of diclofenac potassium, called Cambia, is FDA-approved for migraine.

19:39 – Dr. Hossein Ansari: Basically, diclofenac potassium is an FDA-approved NSAID option for migraine. In this class, NSAIDs may be used on more days per month than triptans, but frequency still needs to be monitored to avoid medication-overuse headache.

19:59 – Dr. Hossein Ansari: For triptans, the usual medication-overuse threshold discussed here is up to about 10 days per month. So one day per week is more restrictive than necessary in this context.

20:20 – Dr. Hossein Ansari: The concern is rebound, or medication-overuse headache.

20:22 – Dr. Adam Lowenstein: And that’s the concern – rebound headache? I’ve also read concerns about triptans and possible stroke or other secondary effects.

20:36 – Dr. Hossein Ansari: Stroke and heart attack, or that’s why contract if the patient has a stroke or heart attack, they cannot use triptan. But the chance that these are causes stroke and heart attack is not usually concerned in the somebody who’s healthy, doesn’t have cardiovascular disease, oruh doesn’t have any heart problem or plaque, atherosclerosis disease or.

20:57 – Dr. Hossein Ansari: something, which most of our patients do not. That’s why it’s and one thing that we know is triptan is very under used or underutilized in United States. So in one of the literature that I was reading, about 25-30 percent of the patient with migraine they are prescribing.

21:20 – Dr. Hossein Ansari: triptan, while over 95% should have triptan. So we have a big gap, and that’s because of all of this information that probably online available, and that’s why probably. But triptan is gold standard asI mentioned, unless there is a clear contra indication needs to be given for all of the.

21:40 – Dr. Hossein Ansari: migraine patients. Many of the patients I see need both an NSAID and a triptan. If a patient has more than 15 or 20 headache days per month and uses a triptan on up to 10 days, they still need another strategy for the remaining days.

22:00 – Dr. Hossein Ansari: So for abortive treatment we use two different strategies: a stepwise strategy and an attack-specific strategy. In a stepwise strategy, I tell the patient to start with an NSAID at the onset of the headache.

22:21 – Dr. Hossein Ansari: For example, take naproxen, diclofenac, or Cambia at the onset and wait about two hours. If the headache resolves, nothing else is needed. If it does not resolve, then the patient can use the triptan.

22:42 – Dr. Hossein Ansari: That’s called the stepwise strategy.

22:43 – Dr. Adam Lowenstein: Okay.

22:44 – Dr. Hossein Ansari: The other approach is attack-specific. Over time, patients often learn which attacks are likely to be milder and which are likely to be more severe. They may use an NSAID for a milder attack and a triptan for a more severe one.

23:07 – Dr. Hossein Ansari: They choose based on the attack. Another way to improve abortive treatment is to provide a non-oral triptan as backup – either self-injection or nasal spray.

23:31 – Dr. Hossein Ansari: Sometimes a patient takes an oral triptan and the pain doesn’t go away quickly enough, or the patient needs to remain active. A non-oral triptan can be useful. Another important indication is a wake-up migraine.

23:54 – Dr. Hossein Ansari: When patients wake up with a migraine, they may already be well into the migraine cycle. When you’re awake, you can take medication as soon as you feel the migraine starting. During sleep, you don’t know when it began; it may have started several hours earlier.

24:14 – Dr. Hossein Ansari: So for wake-up migraine, a non-oral triptan can be useful as a rescue treatment – something that may help keep the patient out of the emergency room. Another strategy to maximize abortive treatment is

24:36 – Dr. Hossein Ansari: the abortive treatment is using some anti-nausea medication, or antiemetics. We have a lot of nausea medications, and a few of them have been shown to be very helpful in migraine. One of them is metoclopramide, or Reglan, and the other is prochlorperazine, or Compazine. These two have the highest evidence.

24:58 – Dr. Hossein Ansari: There is also evidence that these anti-nausea medications can directly help migraine pain. At minimum, they have two clear benefits when used with an NSAID or triptan.

25:22 – Dr. Hossein Ansari: First, they decrease nausea, which can be extremely bothersome for some migraine patients. Second, medications such as metoclopramide increase GI motility.

25:43 – Dr. Hossein Ansari: During a migraine attack, the GI system can slow down. When the stomach and bowel are not moving normally, medication may not absorb as well. Metoclopramide can increase GI motility.

26:06 – Dr. Hossein Ansari: That can help medications such as naproxen or a triptan absorb faster and work more quickly. This is very important and often overlooked. I frequently use an antiemetic with an NSAID or triptan.

26:28 – Dr. Hossein Ansari: That can help the medication act faster and work better, while also helping nausea. So that’s the abortive-treatment discussion of triptans and non-steroidal medications.

26:48 – Dr. Hossein Ansari: There are other classes of migraine abortive treatment available. One class is ergot, which is one of the oldest migraine treatments. At one point they were used for prophylaxis, but because of side effects that use was discontinued.

27:10 – Dr. Hossein Ansari: But for abortive treatment, we still use it. And used to come in two different formulations is injection and also in the nasal spray. However, since last two years almost, we have the oral ergot, which is called ergomar, and uhthat is also available.

27:30 – Dr. Hossein Ansari: So now we have the oral, we have nasal spray and injection ergot available. Those are different classes of the medication, different than triptan, but one thing is important patients who are taking ergot they cannot take triptan within 24 hours of taking ergot. So they have interaction with triptan.

27:53 – Dr. Hossein Ansari: Yes, one or other. 24 hour interval between were commend. So these are the basically three main classes that we have. We used to have the very, very good migraine medication called Midrin, which is the combination of Tylenol with the component called isometheptene, is one of the oldest migraine.

28:16 – Dr. Hossein Ansari: medications, even before Fdas tarted regulating. And unfortunately, within the last two months it’s not available. And I heard the company going to make it an under the other name and probably bring to market with much higher price. But that was very good migraine abortive treatment.

28:36 – Dr. Hossein Ansari: that we had. So these are basically what we have in terms of abortive treatment. There are two classes of medication that some people use for migraine that I do not use and I do not think headache specialists generally use. One of those is

29:01 – Dr. Hossein Ansari: opioid medication, including tramadol. A lot of times I see physicians say tramadol is a non-opioid or a weak opioid, which is not correct. Tramadol is a synthetic opioid. The other class is butalbital-containing

29:22 – Dr. Hossein Ansari: analgesics, Fioricet and Fiorinal. These medications were never made for migraine and were never approved for migraine, but they are commonly prescribed for migraine by general physicians and PCPs, which is a significant problem.

29:44 – Dr. Hossein Ansari: physician PCPs, and that is that is a very big problem. Actually, in the last article that I read, it said 34% in the USA use the butalbital or opioid for migraine. Really? Oh, that’s a huge number.

30:04 – Dr. Adam Lowenstein: We can do like four different podcasts just based on discussing opioids, but you know, on the other hand, I’ve seen so many people who are going to have this visceral response right here and say, okay, well I’ve tried the triptans and they don’t work, so I.

30:30 – Dr. Adam Lowenstein: need my opioids. And you know, I it’s there’s certainly there’s a reasonable argument on both sides of that of that situation. but you know it’s unfortunate that not all medications are going to work for all different people, but you have to you know.

30:51 – Dr. Adam Lowenstein: look at the bad with the good, which opioids have has a lot of a lot of associated issues with it. But I think like I said, you and I should probably have another podcast where we’re just talking about opioids.

31:06 – Dr. Hossein Ansari: And Fioricet that is the Fioricet is actually the biggest problem because you probably don’t the your audience probably it’s good to know that Fioricet is actually it’s out of the market in the entire world except United States, and which is very strange. So this the strength of our FTH.

31:28 – Dr. Hossein Ansari: All of the world, Europe, year sago they removed it abundant from the market because of a lot of issues that happening with Fioricet, and I see on my daily practice. But just simple thing about this Fioricet and opioid, we are going to talk about the anti-CGRP treatment, right? And if you look at the anti-CGRP, there’s a two three anti-CGRP,.

31:49 – Dr. Hossein Ansari: which we are going to talk about that, and there’s a clinical trial designed to approve, right? And in all of these three CGRP, the people with migraine who are taking opioid or butalbital excluded from the study.

32:02 – Dr. Adam Lowenstein: Okay, yeah.

32:03 – Dr. Hossein Ansari: So that means when you’re taking that, you’re not the your chance that you respond to any medication is very low. Right. So this opioid. So this basically abortive treatment. Any question in abortive treatment, and particularly before we jump to the preventive?

32:20 – Dr. Adam Lowenstein: No, I mean the only thing I would say is again, I think we just have to acknowledge that not everything works for everybody. And so you know that that’s why there are headache specialists who have a lot of, as we say, arrows in the quiver, we you know, to try a lot of different things.

32:41 – Dr. Adam Lowenstein: And then at the end of the day, if medications don’t work, then that’s when people end upin my office for surgery. But yeah, I hope I hope I hope all of these issues what we’re talking about is very educational for people to understand why you would progress through different.

33:02 – Dr. Adam Lowenstein: things before giving up on meds. So anyway, let’s yeah, let’s talk about preventatives.

33:09 – Dr. Hossein Ansari: Yes. So preventive. Again, the indication is if patient with migraine had more than one attack per week or five per month, that patient required to be on preventive. This the simplest explanation, but again, we have different tools also. So now say patient needs tobe on preventive treatment. What is the best preventive treatment?

33:30 – Dr. Hossein Ansari: The answer is we do not have the best preventive. So, best preventive is based on the patient. Each patient is different. We cannot look two patient exactly the same and use the same medication. But in general, we have three-class of what we call the traditional migraine preventive treatment.

33:53 – Dr. Hossein Ansari: Number one is antidepressant or anti-anxiety medication. Number two is antihypertensive blood-pressure medication. Number three is antiepileptic or seizure medication. As you can tell, and as we briefly discussed at the beginning, none of these three classes of medication was made

34:13 – Dr. Hossein Ansari: for migraine. But study and trial show that some of those work for migraine. That doesn’t mean all of the anti-blood pressure medication will work. It doesn’t mean all of the seizure medication, just the one that have study and shown we use those. Although we might use the other one as off-label, but that will.

34:34 – Dr. Hossein Ansari: be totally off-label and anecdotal. so that’s why we need to stick with the one that has FTA approval and has enough study to have evidence A or evidence B at least for treatment of the migraine. In terms of the first class, which is antidepressant medication, the oldest one that we use is amitriptyline or.

34:57 – Dr. Hossein Ansari: or Elavil is the brand name. It’s one of the established antidepressants we use at a lower dose for migraine. One important point is that the dose we use for migraine is much lower than the dose historically used for depression. For example, with amitriptyline we use something between 25 and 50 milligrams.

35:19 – Dr. Hossein Ansari: There is a medication related to amitriptyline called nortriptyline, or Pamelor. There is also protriptyline, or Vivactil, from that class. There are three medications in that class, but amitriptyline has the highest evidence. Then we have newer antidepressants, and one with stronger evidence is

35:40 – Dr. Hossein Ansari: venlafaxine, or Effexor. There is also a related medication called desvenlafaxine, or Pristiq. I like that a little better in terms of side effects, but it can be difficult to get insurance approval. So the two main antidepressants are

36:01 – Dr. Hossein Ansari: amitriptyline and venlafaxine. Then we have antihypertensive, or blood-pressure, medications. Beta blockers have the strongest evidence for migraine prevention: propranolol, nadolol, timolol, and metoprolol.

36:22 – Dr. Hossein Ansari: This four beta blockers that we use the most. After beta blocker, we have calcium blocker like verapamil, and also the medication called flunarizine, which we don’t have in the US but Mexico and Canada have, and that’s why I have a lot of patients on that medication. And also some of these what we call angiotensin-related.

36:44 – Dr. Hossein Ansari: antihypertensive medications, such as lisinopril and particularly candesartan, have some evidence for migraine prevention. The third class is seizure medication, and two medications in this class have FDA approval.

37:05 – Dr. Hossein Ansari: One is topiramate, or Topamax, and the other is Depakote, which is valproic acid. One very important factor in preventive treatment is using the correct dose, or target dose.

37:25 – Dr. Hossein Ansari: So if somebody I see this all the time, patient comments say, Oh, I tried all of this. When you look at their record, it’s say, Okay, yeah, patient tried amitriptyline 10milligram. So I’m not expecting that anybody in 10 milligram amitriptyline responds. Or patient can, oh, I tried it, and look, okay, I saw 20 milligrams of propranolol. Nothing. Basically, you didn’t take anything.

37:47 – Dr. Hossein Ansari: But that’s happened a lot. And I understand why, because titration of this medication is not easy. So when you put somebody on propranolol and you want to go to the target dose, which is minimum 80 milligram, to use between 80 to 120 milligrams of propranolol. If you start somebody in 80milligram of propranolol, that.

38:07 – Dr. Hossein Ansari: patient will take one or two dose and they’ll stop and done because of side effect. You need to tit rate this medication every week. And that’s not easy again with the busy practice that all of the physicians have, who is going to see the patient every week or every two weeks to titrate the medication. Sure. So that’s very difficult. Or the same thing with Topamax. Topamax target dose is 100milligram.

38:30 – Dr. Hossein Ansari: But if you give somebody 100milligram Topamax today, you won’t see that patient tomorrow, isn’t probably doesn’t with horrible side effects. Yeah. So that is the problem. The tit ration is the biggest problem. Slow tit ration, then you need to give time to the patient to basically become effective.

38:50 – Dr. Hossein Ansari: The other important thing about the preventive treatment, because these are daily medications, of course, they will have side effects, right? You’re taking daily medication and each daily medication might have side effects. And some of them has more, some of them less. But also some patients might develop side effects to other medications, but not to the medication X but not to the Y.

39:12 – Dr. Hossein Ansari: and the vice versa.

39:14 – Dr. Adam Lowenstein: Even within the same class.

39:15 – Dr. Hossein Ansari: Yes, exactly. Right. So that is very important to discuss with the patient about the side effect and also look at the patient’s other comorbidities. For example, if patients have asthma, bad asthma, so you we cannot use propranolol. You are going to give the patient asthma attack. If patient have the kidney stone or history of kidney stones, if you.

39:37 – Dr. Hossein Ansari: give topamax, the patient will have another kidney stone. I saw the patient just two months ago. This poor guy had nine surgeries for kidney stones and he was in Topamax for because of Topamax kidney stone and a nine time lithotripsy, and this a horrible. I mean, so you need to ask all of these, and that’s not easy. Or if the patient is really overweight or obese using.

40:00 – Dr. Hossein Ansari: amitriptyline, it’s not a good idea because you are going to give more weight gain. And the same thing with depakote, cause weight gain and also hair loss. That’s why it’s not even possible in most of my patients. So most of my patients are female between 20 to 40, and the last thing that I want to tell my patient is that I’m going to.

40:21 – Dr. Hossein Ansari: give a medication that make you fat and bald. Right? So no way can you lose that. that is that side effect isis important. So you need to when people prescribe the preventive, they need to know the side effect very well, otherwise, that will be a problem and patient the treatment won’t be.

40:42 – Dr. Hossein Ansari: successful. And this probably the main reason that medical treatment has not been as good for migraine because of the side effect.

40:50 – Dr. Adam Lowenstein: And there can be side effects as well for tryptans, correct?

40:54 – Dr. Hossein Ansari: I mean, a lot of people abortive, you’d be the thing. I mean, even if side effect does at the minute, done. But preventive is daily, you have to take every day side if it’s not going to anywhere.

41:03 – Dr. Adam Lowenstein: So but I’ve had people who told me that triptans they didn’t liketriptans because it wiped them out and you know makes them really tired and so even side effects of the triptan, which happened 10 to 15 percent of the patient called triptan sensation.

41:16 – Dr. Hossein Ansari: Even side effects of triptans, which happen in a minority of patients and are sometimes called ‘triptan sensations,’ don’t necessarily mean that all triptans will cause the same problem. If a patient has a triptan sensation – such as chest discomfort or throat symptoms – with sumatriptan or Imitrex, we can still consider other triptans.

41:39 – Dr. Hossein Ansari: but again, that’s separate lecture that we can give. But yeah, yeah, we shouldn’t give up on the triptan that easy. That triptan is really good medication for migraine. So this tricky class of the preventive. Then we have Botox, which of course is one of the old now.

41:59 – Dr. Hossein Ansari: is one of the oldest technique or oldest treatment that we have for migraine for last 10-15 years, even we are using it. One thing about the Botox that people need to know it’s only approved for chronic migraine. Chronic migraine means patient had 15 or more headaches per month. Yeah, and so the patient we who are not chronic, Botox is not.

42:23 – Dr. Hossein Ansari: even FDA approved, although alot of other colleagues might use it, but it’s basically off-label and not FDA labeled to use it. And that is very good treatment that we have. We still use it, and I have I don’t remember the day that I do not have Botox injection in my office, so basically it’s every.

42:45 – Dr. Hossein Ansari: day. and we use with a different technique. I use a little different than what is most of the neurologists does because I actually learned the Botox from non-neurologists when I started it. Right. And so but that is very, very good treatment that we have.

43:06 – Dr. Adam Lowenstein: And here again, another you can do a whole other podcast on that. I’ve I cover that a lot onmy website, headache surgery. com. But we yeah, it’s one of the issues that I have is that I see patients who’ve had Botox and they you know it didn’t work,.

43:27 – Dr. Adam Lowenstein: and people who come in with you know inflammation, occipital problems, and they had the what is it, 33 injections of the normal 31 injections from the FDA. seems like a honestly a waste of a lot of Botox in parts of the head that are not affected.

43:49 – Dr. Adam Lowenstein: but yeah, we can have we’ll we’ll have another boat another episode.

43:57 – Dr. Hossein Ansari: Yeah, overuses I agree actually I was in There was a meeting called Toxin meeting, which is a very good meeting, actually. That means different speciality, all of the specialty that I use Botox, they come to that meeting. And I attended that meeting, andI had the actually lecture that was in Spain 2017.

44:17 – Dr. Hossein Ansari: And so we’re talking, and actually, one of the speakers was the ear-nose throat physician, and was talking about the Botox. And he during his presentation he actually made a joke that neurologists overuse the Botox. And I agree, we’re overusing, we really don’t need that many injections. But again, this again.

44:37 – Dr. Adam Lowenstein: But anyway, that’s a yet another podcast to yeah, listen for on future episodes. But okay, so let’s let’s move on.

44:47 – Dr. Hossein Ansari: Move on. In terms of newer preventive treatment, what really changed the way we practice is the anti-CGRP class. Just a quick description of CGRP: CGRP is a neurotransmitter – calcitonin gene-related peptide – involved in neuroinflammation and migraine.

45:11 – Dr. Hossein Ansari: calcitonin gene-related peptide. That is the chemical in the brain that causes inflammation. And an inflammation in the brain, which is a neuroinflammation, is the key component of creating the headache. So now when we talk about the migraine, we call migraine is.

45:31 – Dr. Hossein Ansari: the neuroinflammatory disease. And CGRP is the key player in this neuroinflammatory. So that is in terms of the what is CGRP. And now what happened if we uhde crease the CGRP? Because studies show that in the patient with migraine, CGRP level increase.

45:53 – Dr. Hossein Ansari: So if you can decrease the level of CGRP, it will be helpful for migraine. This was theory. Although it wasn’t this easy. Now it’s very easy, it seems very easy. But if you look at the discovery of CGRP, CGRP actually discovered back in 1982 here in university of California in San Diego, the where I’m working by two pharmacy PhD doctorate,.

46:16 – Dr. Hossein Ansari: basically physician, they discovered it at 1982. Then they didn’t know what exactly it does until 90, which Dr. Edvinsson, the current president of International Headache Society, he for the first time explained that CGRP is a player in migraine, and then 91 when Dr.. Goadsby by continued that discussion and they confirmed.

46:40 – Dr. Hossein Ansari: yes, CGRP. So 90, 91, we know that the CGRP is a key player, or at least one of the key players for migraine, but we didn’t have anything until 2018. So it takes 28 years until we know what it is, until the medication that works on that. So it that means a lot of work done until that.

47:03 – Dr. Hossein Ansari: So now we have three medications that work on CGRP and antagonize the CGRP pathway. These are anti-CGRP monoclonal antibodies. They are either humanized or fully human monoclonal antibodies. The first one was made by Amgen and

47:26 – Dr. Hossein Ansari: launched by Amgen and Novartis in May 2018. That’s called Aimovig. Then two others came within about a week of each other in September 2018: AJOVY by Teva Pharmaceutical and Emgality by Eli Lilly.

47:49 – Dr. Hossein Ansari: Now we have three available. One major difference is that Aimovig blocks the CGRP receptor, while AJOVY and Emgality block the CGRP molecule itself. The beauty of this class is that treatment is typically monthly rather than daily.

48:11 – Dr. Hossein Ansari: other two AJOVY and Emgality, they are blocking the molecule itself. They directly block the CGRP. And the beauty of this class of the medication is once a month rather than every day. And actually, one of them AJ youcan do quarterly rather than.

48:33 – Dr. Hossein Ansari: once a month. Three injection every three months. But all three standard treatment is one every month. SubQ injection, they come with the auto-injector pre filled syringe, is very easy to use and they do not even go through the liver to metabolize through the liver.

48:54 – Dr. Hossein Ansari: That means there is no interaction with the other medication that the patient might take and doesn’t do anything with the patient’s other underlying disease. If you have asthma, if a kidney stone, the provider you have, there’s no problem because they won’t have any problem with any of other systems because that goes SubQ to the blood and then.

49:15 – Dr. Hossein Ansari: through the blood metabolize to the system or phagocytosis basically what they remove the molecule from the body. So this the new tree class that we have and kind of change the stigma of the migraine, change the practice because now we have something that specifically made for migraine.

49:37 – Dr. Hossein Ansari: as I mentioned, the other three classes or four classes, even Botox, which we’re using, is not made for migraine. Botox was basically your drug for a while, a plastic surgeon, right?

49:48 – Dr. Adam Lowenstein: Yeah, it’s done for aesthetics, and exactly but now we see we people use it in muscle spasms all over the body.

49:55 – Dr. Hossein Ansari: Yeah, using hyperhidrosis and everything. Right. Yeah. So basically that is so these are the first ever migraine preventive treatment. Any question in CGRP?

50:10 – Dr. Adam Lowenstein: That’s that’s a that’s a trick question unto itself. I’m sure we could talk about cgrp also for quite some time. I guess the yeah, the my experience is skewed because the people that I see are the people who fail everything else, right? So you try this medication, that medication, and none of them.

50:31 – Dr. Adam Lowenstein: work, or the side effects don’t work for them or for multitude of reasons, and then they end up in my office for nerve decompression surgery. and so is there a I mean can you briefly discuss why X, Y, or Z would not work for a given patient, or are we still.

50:56 – Dr. Adam Lowenstein: trying to figure that out? You’re talking about the additional treatment or well, I mean, you know, I guess youcan since there are no except for the CGRP blockers, the preventatives have never been specific for migraines. And so you could have certainly people who just don’t tolerate.

51:16 – Dr. Adam Lowenstein: the low heart rate that associated with a beta blocker or the exhaustion that’s associated with antidepressants. and certainly there are people who I’ve had that have tried tryptans and they say they don’t work for.

51:40 – Dr. Adam Lowenstein: them. and there’s certainly lots of reasons Botox could not work, and primarily, again, I think a lot of people who don’t necessarily know how to properly inject Botox for migraines are part of the issue because I’ve I’ve seen a lot of.

52:00 – Dr. Adam Lowenstein: people who just are getting injections in the wrong spot. and then there’s CRGP, CGRP drugs that I think from what I see work for some people but don’t don’t seem to work for others. So I guess the would I be correct in saying that you.

52:23 – Dr. Adam Lowenstein: progress through these different types of medications as needed? And you know, if one works, that’s great. If one doesn’t work, then you move on to the next one, and then at some point if medications don’t work, then you move on to other modalities.

52:44 – Dr. Hossein Ansari: Yes, exactly. So in term of the traditional treatment, why it failed, one simple one of the main reasons is because as we discussed, these are not made for migraines. So you don’t expect that something that’s not made for that condition helps for all of the patients, right? Yes. Second of all, the side effects.

53:05 – Dr. Hossein Ansari: So a lot of people do not tolerate the side effect in the dose that they need to be in. That is probably even more important than that. If patient, if all of the patients can tolerate the traditional preventive with the target dose, we certainly will have higher side effect, higher response rate.

53:29 – Dr. Hossein Ansari: But again, the side effect is the problem. In terms of the CGRP, also we are not expecting to be 100% because although we know CGRP isa key player in the neurogenic inflammation, but it is not the only player. So we have other neurotransmitter that play a.

53:50 – Dr. Hossein Ansari: role. So we have the different type of the migraine. Migraine is the genetic disorder we discussed in our first podcast. I believe the migraine is the complex genetic neurological disorder. That doesn’t that means not all of the patients have the similar gene. Yes, in a majority of the patients, CGRP seems to be the key player, and that’s why the response rate is really, really.

54:15 – Dr. Hossein Ansari: high if you use in the correct patient. So I really see very few failure, and actually the people that fail the CGRP and send itto me when you go and dig in, they have some other reason. For example, they are still taking opioid. So if you take opioid, CGRP is not going to be effective. And there’s a pharmacologic reason for that because opioid.

54:38 – Dr. Hossein Ansari: increased the CGRP. So you’re increasing CGRP with opioid and you’re trying to give anti-CGRP. So you’re wasting your time. Okay. Interesting. So that is the thing. but yeah, there’s definitely won’t be 100%. -huh. And again, we don’t have any cure for any disease that have a genetic basis, right?

54:59 – Dr. Hossein Ansari: We cannot cure the diabetes, we cannot cure the hypertension. The migraine is like that. This that some gene is going on, and we just can manage it better. And yeah, but if there is traditional treatment and more recently CGRP fail, there’s alot of other options.

55:20 – Dr. Hossein Ansari: We use a lot of procedures beside Botox for the migraine, even for many years, and one of those procedures are nerve block. And the nerve block is the lidocaine injection in the different nerve that wedo, and that’s very helpful. I have a patient that comes every two weeks for nerve block.

55:42 – Dr. Hossein Ansari: for last three years because that patient had this single trigger point and she doesn’t want to take daily medication and that works. So if that’s the case, we do that. There is other basically modalities like devices. There is a lot of new devices that your audience might hear. These are neuro stimulator uhde vices that is in the market,.

56:06 – Dr. Hossein Ansari: There are several newer external neuromodulation devices that your audience might have heard about. These include the Cefaly device for the supraorbital nerve, SpringTMS, and gammaCore for vagus nerve stimulation. These are devices available for migraine treatment.

56:26 – Dr. Hossein Ansari: for migraine treatment. in my experience, those are not very effective, or at least not very effective in the patient who failed a lot of other medication. Yeah, if you use in the firsthand patient, it probably will be helpful, but in firsthand patient any other treatment will be helpful.

56:46 – Dr. Adam Lowenstein: And I’ve actually we’ve we’ve had a we’ve had a pain specialist on the podcast, and he as well, and he’s the kind of guy that would actually be putting those in, and he feels exactly the same way. Okay, so that’s different.

56:57 – Dr. Hossein Ansari: The pain specialist, actually, the one that you did, these are that I’m talking about these are external stimulators. They basically oh, external stimulator. Yeah, this a device and patient does itself. The other one that is occipital stimulator, they place lead, that is actually there’s a huge study done in Mayo Clinic years ago, and it showed that failed, and it’s never approved for.

57:18 – Dr. Hossein Ansari: migraine. And in my experience, also the side effect and complication is way higher than basically possible or potential benefit. That’s why that’s something that I do not recommend. So between that placement of the occipital and your procedure, which is occipital decompression, I don’t want to.

57:41 – Dr. Hossein Ansari: be biased, but in my opinion occipital decompression is safer and more effective. Since we’re talking about the procedure that is your niche – migraine trigger-point deactivation surgery, first described by Dr. Guyuron around 2000 to 2001 – that is one of the procedures used for selected patients.

58:01 – Dr. Hossein Ansari: surgery, which invented by Dr. Guyuron back in first time actually explained in 2000-2001. And since then he’s doing that. That is one of the procedures uhthat we do for some of our patients. And the question which patient will be candidate for that and which patient is not, this, I think, is one podcast that I.

58:25 – Dr. Hossein Ansari: would like to do because I want to give my opinion in that we don’t need we or we don’t have to do in the patient that fail everything. That’s my opinion. And it’s very similar to other procedure that we have in the in the basically neurology world. We have the condition called trigeminal neuralgia, and.

58:46 – Dr. Hossein Ansari: that’s a condition that causes prompt compression of the blood vessel in the trigeminal nerve in the brain. And when I see that patient inmy clinic, I always recommend surgery at first because that’s kind of a cure. The same thing with the trigger point. I don’t wait until patients fail everything because.

59:07 – Dr. Hossein Ansari: you’re basically you want to waste three, four, five years of the patient’s life with being miserable and suffering while you know that this procedure, which is relatively safe, right? We’ll talk about that hopefully in your podcast, and you probably can tell about the complication and side effect. But if you compare this with this occipital stimulator, which.

59:31 – Dr. Hossein Ansari: the pain doctor does, this way safer and less side effect.

59:36 – Dr. Adam Lowenstein: So I Yeah, we’ll we’ll have to definitely do. I mean, I in the next weeks to months, I’ll I’ll probably do a podcast myself on what Ido, which is this trigger point and nerve decompression surgery invented by Dr. Guyuron, who is a friend of both of ours and somebody.

59:59 – Dr. Adam Lowenstein: that we both have a tremendous amount of respect for. but yes, it is I agree that you know our success rate and our safety profile is outstanding for that procedure. It just works, as we say. But again, a different podcast.

01:00:20 – Dr. Adam Lowenstein: and if any other comments that you want to make about medications? Because the one thing that I’m taking away from this how important it is to see somebody who really knows what they’re talking about, because you’re you’ve got preventatives,.

01:00:42 – Dr. Adam Lowenstein: you’ve got abortives, you’ve got the newest drugs, you’ve got d all of these different side effects profiles and all of these different dosage profiles, and it’s a lot of information. you know, people ask me about medications all the time, and I defer to headache specialists because that’s not.

01:01:04 – Dr. Adam Lowenstein: my world. And so I really think it’s important to make sure that patients are seeing people who are well versed in the specialty of headache.

01:01:16 – Dr. Hossein Ansari: Exactly. And now you can actually refer to this podcast because I think we discussed the classes, abortive previous. This very important. One thing that I want your audience to know the difference between preventive and abortive treatment, and not using abortive treatment more than it’s supposed to be, particularly over-the-counter medication. That will make the headache worse.

01:01:39 – Dr. Adam Lowenstein: Yeah. All right. Well, Dr. Ansari, again, thank you very, very much. I look forward to hopefully many more of these podcasts. I think today we’ve identified several other areas that we can that we can talk about. Sure, sure, exactly.

01:01:58 – Dr. Hossein Ansari: Thank you very much again, and hopefully this helpful for your audience, and they can get some benefit and some educational information about the headache and migraine and treatment by the fantastic.

01:02:11 – Dr. Adam Lowenstein: Okay. Thanks, everybody, for listening, and we all look forward to hearing from Dr. Ansari again. Thanks very much. Hey, everybody, this is Dr. Lowenstein once again, and I have two last things to ask of you. Firstly, the thing you can do for fellow headache sufferers is

01:02:32 – Dr. Adam Lowenstein: to please remember to subscribe and rate our podcast. The more ratings and subscriptions that we get, the more visibility that we’ll get, and the more listeners will be able to find us, and the more help and information we’ll be able to provide the huge population of people who suffer from headache pain. Secondly, please remember that the treatment of headaches of all types is very individualized. The purpose of this podcast is not to give medical advice, so.

01:02:55 – Dr. Adam Lowenstein: please use the information here on this podcast and elsewhere that you’re here on the internet to broaden your knowledge, but consult with your physician before acting on any information that you hear on the podcast or see on YouTube or read anywhere on the internet. I, as a physician, don’t necessarily endorse the opinions or practices of my guests. And if you have particular questions that you’d like to consult with me directly about, please call our headache surgery.

01:03:17 – Dr. Adam Lowenstein: center. Our phone number is 805-969-9004, or you can email us at info@headachesurgery.com, and my staff will set up a consultation and we can discuss your specific case over the phone or in person. Our website is filled with information as well, and that is headachesurgery.com. Thanks and best wishes from all of us here at the Headache 360

01:03:39 – Dr. Adam Lowenstein: Podcast.