Cheap Migraine Drugs More Effective Than New Expensive Ones

By Pat Anson

Migraine treatment drugs known as triptans are more effective in relieving acute migraine pain than new expensive medications and should be used more widely, according to new study published in The BMJ.

A team of researchers at Oxford University analyzed the results from 137 clinical studies to see which migraine drugs were more effective in helping patients become pain-free after two hours and whether that relief was sustained 24 hours later. Nearly 90,000 people participated in the studies, over 85% of them women.

Four triptans - eletriptan, rizatriptan, sumatriptan, and zolmitriptan – were rated the best overall, ahead of rimegepant (Nurtec), ubrogepant (Ubrelvy) and lasmiditan (Reyvow) in efficacy and tolerability.

“Overall, the results of our network meta-analysis suggest that the best performing triptans should be considered the treatment of choice for migraine episodes owing to their capacity for inducing rapid and sustained pain freedom, which is of key importance for people with migraine,” wrote lead author Andrea Cipriani, MD, a professor of psychiatry and director of the Precision Psychiatry Lab at Oxford.

Triptans work by narrowing blood vessels in the brain and preventing the release of chemicals that cause migraine pain; while rimegepant and ubrogepant inhibit calcitonin gene-related peptides (CGRPs), a protein that triggers pain. Lasmiditan reduces pain by binding to serotonin receptors in the brain.

The drugs’ mechanisms of action are different and so is their cost. A packet of 6 tablets of eletriptan costs about $106, while a similar-sized packet of rimegepant (Nurtec) costs $1,061; ubrogepant (Ubrelvy) costs $1,097; and lasmiditan (Reyvow) is priced at $790. The cost of those three drugs is much higher because they are only available as brand name medications, while triptans are widely available in cheaper generic formulations.

Despite their cost and extensive marketing promoting their use, lasmiditan, rimegepant, and ubrogepant were rated no more effective in treating migraine pain than over-the-counter drugs such as acetaminophen (paracetamol) and non-steroidal anti-inflammatory drugs (NSAIDs). Researchers say those OTC pain relievers should be considered second line options, if triptans are ineffective.  

“While the recent introduction of lasmiditan, rimegepant, and ubrogepant has expanded options for the acute treatment of migraine, the high cost of these newer drugs, along with the substantial adverse effects of lasmiditan (dizziness), suggest their use as third line options, after the less expensive, similarly efficacious, second line options,” researchers said.

“Limited access to triptans and their substantial under-utilization represents missed opportunities to offer more effective treatments and deliver better quality of care to people who experience migraine.”

Some people can’t take triptans due to cardiovascular problems or unwanted side effects, but researchers say the best performing triptans should be included in the World Health Organization’s List of Essential Medicines to help expand their use.

Another recent study also rated triptans as superior to other migraine medications, although that research didn’t include the newer CGRP inhibitors.

Migraine affects about 39 million people in the United States and 1.1 billion worldwide. In addition to headache pain, migraine can cause nausea, blurriness, and sensitivity to light or sound. Women are three times more likely to suffer from migraines than men.  

How I Escaped From the Darkness

By Mia Maysack, PNN Columnist

At this moment in my life, I’ve chosen to continue on -- out of spite, if nothing else. I’ve chosen to quit entertaining the intrusive, dark thoughts that creep in and try to take over.

However, as an individual enduring a chronically ill and persistently pained existence, I’ve spent a lot of time torn between putting forth my best efforts for a great life and just wanting it all to be over.

We’re urged to reach out to loved ones when we’re sad or depressed. But everyone has their own problems and most likely wouldn't know what to do with ours. We don't want to burden anyone, despite their claims that they'd rather get a call about someone’s troubles than receive an announcement about their death.

Our society is sick enough to promote or even force life, but then does little to improve the quality of it for people who need it most.

Rather than sitting with you in the thick of your sh*t, we’re assured that "You got this!" as they wash their hands clean. Your very real experience is disregarded because it makes people uncomfortable.

I realized death was something I’d lusted after when a friend recently “unalived” herself. Underneath the immense hurt and grief, I was soon overcome with envy.

Each time I'd work my nerve up, there was always a reason not to, for the sake of other people. Someone's birthday or a holiday would be around the corner. Somebody would reach a milestone I'd wish to celebrate. Then my deep longing would be set to aside for a while.

I'd even forget about it sometimes, despite the constant gnawing of despair that’d inevitably claw its way through my soul from the inside out.

I would tune out the despair and do my best to concentrate on things like blessings and gratitude instead. Then I'd get down on myself for fixating on all that was "wrong" in my life, as opposed to simply allowing all that was *right* to be enough.

There came a point that it didn't matter how much of myself I gave away to the world, the extent I'd show up for others, volunteer my time, give away my possessions or donate my money.

It also didn't seem to make much of a difference how busy I kept myself or how many meditations I did on thankfulness; with the reminder that we're all one in this world, connected by the singular vibrational pulse of our shared universe.

Blah, blah, blah.

I did everything I could reasonably think of to pour into myself. I loved fiercely, gave my all to those I cared about, did what I could to assist others in their misery, and made it my life's mission to ease suffering in any minor way that was within my capabilities.

The truth is that, even without my spirit exiting this realm, I've already died several times over.  

The selfishness of it all is when a point is reached that we’re no longer able to love this world or those in it more than we absolutely despise existing.

I think this is where people get things twisted when they attempt to make sense of why someone would decide to end their life.

It baffles me to comprehend that there are some who've never felt like this, who are so privileged that they cannot even begin to fathom or wrap their head around it. It also rubs me wrong when people try to make another person’s death all about themselves.

Can you imagine how the actual individual must have felt to reach a point that this was believed to be their absolute last, best and only option?  I think as humans we can only endure so much, to the point when there is no turning back.

Being on your own to sort through it all certainly doesn't make things easier. Your loved ones often misunderstand you or just skip straight to worry. The professionals approach things from a data standpoint and are quick to blemish your mental health record. Authorities report and may even incarcerate you “for your own protection.” Communities consider open discussion of these topics taboo. And the churches will condemn you to hell --- as if you don't already feel like that's where you're living.

Where does a person turn?  Where can we get actual help?

I have come to accept that my most authentic answer, based on my own experience, was nowhere. Nowhere other than within.

I’ve shared what has worked for me to make it as far as I have. I’ve also been very candid about my less than perfect moments. I’ve elevated those around me and did everything within my power to uplift each person I'd ever come into contact with.

I think we can hurt to a point we just do not recover from it. We can only take so much and each of us has a limit. There are certain things that can occur in a person's life where their brain doesn't return to a state of normalcy. You reach a sort of depletion that is permanent, to the point it doesn't seem to matter anymore. Because what we’re enduring feels like it’s not survivable.

A person can reach a point of believing that the pain of their absence cannot come close to the agony they’ve endured just about every day of their life.

I've chosen to prefer being alive and in pain, as opposed to laying 6 feet underground experiencing nothing. That's the bottom line for me. I think the fact that we've hushed these conversations for so long plays a role in killing people. As a society, we need to take a look at that and accept some responsibility.

What we don’t tend to, withers. Thus, I am taking the remaining power I still possess and using it to water myself. I invite you all to do the same.

Mia Maysack lives with chronic migraine, cluster headache and fibromyalgia. She is a healthcare reform advocate and founder of Keepin’ Our Heads Up, a support network; Peace & Love, a life coaching practice; and Still We Rise, an organization that seeks to alleviate pain of all kinds.

Migraine Drug May Prevent Headaches in Hot Weather

By Pat Anson, PNN Editor

With a dangerous heat wave expected this week in the Midwest and Northeast, the National Weather Service has issued “heat alerts” from Iowa to Maine through Friday. Temperatures are expected to reach the mid to upper 90’s, although it will feel hotter due to high humidity in some areas.

Health experts are giving the usual precautions about heat safety, such as staying hydrated and avoiding strenuous outdoor activity, but migraine sufferers may just want to stay inside in a cool, dark place. While there are no clear links between hot weather and migraine, the American Migraine Foundation says that seasonal changes in weather can trigger a migraine attack.

There are currently no FDA-approved treatments for the prevention of weather-related migraines, but according to a preliminary study, one of the new migraine drugs that block proteins known as CGRPs (calcitonin gene-related peptides) may help prevent headaches in hot weather.

A team of researchers analyzed over 71,000 daily diary records of 660 patients with episodic migraine, comparing them with local weather data on the same days. They found that for every temperature increase of 10 degrees Fahrenheit, there was a 6% increased risk of a headache.

“What we found was that increases in temperature were a significant factor in migraine occurrence across all regions of the United States,” says lead author Vincent Martin, MD, director of the Headache and Facial Pain Center at the University of Cincinnati. “It’s pretty amazing because you think of all the varying weather patterns that occur across the entire country, that we’re able to find one that is so significant.”

When researchers took a closer look at migraine patients being treated with fremanezumab, which is sold under the brand name Ajovy, the association between hot weather and headaches completely disappeared.

Ajovy is an injectable migraine prevention drug made by Teva Pharmaceuticals, which funded the study. Teva also paid consulting fees to Martin, who is president of the National Headache Foundation.

“This study is the first to suggest that migraine specific therapies that block CGRP may treat weather associated headaches,” says co-author Fred Cohen, an assistant professor of medicine at Icahn School of Medicine in New York City.

Findings from the study were recently presented at the American Headache Society’s annual meeting in San Diego, California. If the findings are confirmed in future studies, Ajovy and other CGRP inhibitors have the potential to help migraineurs who suffer from weather-related triggers.

The medications are not cheap. The listed cost for Ajovy is $640 for one monthly dose, although out of pocket costs will vary depending on insurance.

Work Comp Claims for Opioids Down Significantly

By Pat Anson, PNN Editor

Workers’ compensation claims in the U.S. for opioids and other pain relievers fell significantly in 2023, one of the largest drops the work comp industry has seen in years, according to a new report.

San Diego-based Enlyte analyzes drug utilization and spending trends annually for property and casualty insurers. The company’s Drug Trends Report for 2023 estimates that overall opioid use per claim fell by 9.7 percent, with the use of sustained-release opioids such as oxycodone down more than 10 percent.

Surprisingly, work comp claims for non-opioid pain relievers also fell, even though they are increasingly prescribed as alternatives to opioids. Claims for non-steroidal anti-inflammatory drugs (NSAIDs) fell by 3% last year, with anticonvulsants like gabapentin down 7.4% and antidepressants such as duloxetine falling 6.1%. 

"This, by far, marks one of the largest drops in opioid utilization we've seen in years," Nikki Wilson, PharmD, senior director of clinical pharmacy solutions at Enlyte, said in a press release. "In addition, opioid alternatives commonly prescribed to manage acute and chronic pain also experienced decreases in utilization per claim, although to a lesser degree than opioids."

Enlyte said the decline in opioid use was “supported by prescribing guidelines,” noting that claims for high-dose opioid prescriptions have fallen for nine consecutive years. The 2016 CDC opioid guideline urged doctors not to prescribe doses higher than 90 morphine milligram equivalents (MME) per day. Although that recommendation is voluntary, it has taken root in many laws, regulations and insurance policies governing the use of opioids.

As a result, non-opioid analgesics and muscle relaxants are used more often than opioids for pain management during the first two years of a work comp claim. Only afterwards are sustained-release opioids used more frequently for chronic pain caused by job-related injuries.

Even though opioid use has fallen dramatically in recent years, opioids remain the top therapeutic class for claims, followed by NSAIDs, anticonvulsants, muscle relaxants, antidepressants and topical medications. Those six therapeutic classes represent over two-thirds of the prescription drug claims in 2023.

Respiratory and Migraine Drugs  

While the overall cost of prescription drugs fell slightly (down 0.2%) in 2023, the price of respiratory and migraine medications rose significantly, up 14.7% and 10.2%, respectively.

Newer migraine drugs that block calcitonin gene-related peptides (CGRPs) are some of the most expensive medications, with the average wholesale price of a Nurtec prescription reaching $1,916 and $1,654 for a Ubrelvy prescription.      

"Basically, what's driving these trends are the costs of the top three medications in their respective classes," Wilson said. "For instance, for migraine medications, Nurtec ODT is prescribed about 15% of the time yet makes up more than 31% of the total drug spend in this category. Similarly, respiratory medication like Trelegy Ellipta is prescribed about 10%, but accounts for nearly 19% of all respiratory medication total costs."

Enlyte reported the number of retail and mail order prescription drug claims is trending downward due to an “evolving work environment.” More people are working from home and as independent contractors, reducing the number of on-site job injuries and employee compensation claims.  

Experts Say CGRP Drugs Are First-Line Therapies for Migraine Prevention

By Pat Anson, PNN Editor

Migraine medications that block calcitonin gene-related peptides (CGRPs) are “equal to or greater” than other migraine prevention drugs and should be considered first-line therapies, according to a new guideline from the American Headache Society (AHS).

It’s the first time the organization has endorsed CGRP inhibitors for migraine prevention, despite their high cost and limited availability due to insurance requirements. Many insurers have step-therapy policies that require patients to start with cheaper first-line treatments before trying other drugs.

"Moving CGRP-targeting therapies to the first line of treatment could have a transformational impact on the prevention of migraine attacks and their associated burdens," Andrew Charles, MD, AHS president and lead author of the guideline recently published in the journal Headache. 

CGRP inhibitors block a protein that binds to nerve receptors in the brain and trigger migraine pain. Since 2018, the FDA has approved over half a dozen CGRP medications for migraine prevention and/or treatment, the biggest innovation in migraine therapy in decades.   

Older drugs that have long been used for migraine prevention were originally developed for other conditions. They include amitriptyline, a tricyclic antidepressant; simvastatin, which is used to control cholesterol; topiramate (Topamax), an antiseizure medication; and beta-blockers commonly used to control blood pressure.  

The AHS says there is growing “real world” experience that CGRP inhibitors work better than the older, repurposed medications.

“The evidence for the efficacy, tolerability, and safety of CGRP-targeting migraine preventive therapies is substantial, and vastly exceeds that for any other preventive treatment approach,” the AHS said. “The data indicates that the efficacy and tolerability of CGRP-targeting therapies are equal to or greater than those of previous first-line therapies and that serious adverse events associated with CGRP-targeting therapies are rare.”

The biggest problem with CGRP inhibitors is their cost, which can reach tens of thousands of dollars a year. Eight doses of Nurtec, a tablet taken daily, cost over $1,000; while the listed price for Emgality is $706 for a self-injectable syringe used monthly. Prices will vary, depending on insurance and whether a patient qualifies for discounts or patient assistance programs.

By comparison, amitriptyline and simvastatin are bargains. A bottle of 30 simvastatin tablets will cost about $14, while amitriptyline costs about $13 for a supply of 28 tablets. A recent study suggests that amitriptyline and simvastatin work just as well as CGRP inhibitors in reducing the need for medications to treat migraine pain, an indication that they are effective at prevention.

Despite the disparity in cost, the AHS maintains the overall benefits of CGRP inhibitors may justify the price. There are substantial hidden costs to migraine attacks, which can result in lost productivity, income, education, and personal relationships.   

“We recognize that the CGRP-targeting preventive therapies are significantly more expensive on a yearly basis than most of the previously established therapies, and some argue that this expense is a primary consideration in clinical decision-making,” the AHS said. “On the other hand, we argue that it is critically important to consider not only the direct cost of the treatment but also the substantial costs to the individual and society if effective treatment is delayed.”

Migraine affects about 39 million people in the United States and 1.1 billion worldwide. In addition to headache pain, migraine can cause nausea, blurriness, and sensitivity to light or sound. Women are three times more likely to suffer from migraines than men.  

Neurological Conditions Now Leading Cause of Chronic Illness

By Pat Anson, PNN Editor

The number of people living with neurological conditions such as migraine, diabetic neuropathy, epilepsy, stroke and dementia has risen significantly over the past 30 years, making it the leading cause of chronic illness worldwide, according to a new analysis published in The Lancet Neurology.

An international research team estimates that over 3.4 billion people – about 43% of the global population – had a neurological condition in 2021, replacing cardiovascular disease as the leading cause of poor health.

“The worldwide neurological burden is growing very fast and will put even more pressure on health systems in the coming decades,” said co-author Valery Feigin, MD, Director of the National Institute for Stroke and Applied Neuroscience at Auckland University in New Zealand.

“Yet many current strategies for reducing neurological conditions have low effectiveness or are not sufficiently deployed, as is the case with some of the fastest-growing but largely preventable conditions like diabetic neuropathy and neonatal disorders. For many other conditions, there is no cure, underscoring the importance of greater investment and research into novel interventions and potentially modifiable risk factors.”

A total of 37 disorders affecting the brain and nervous system were included in the study. Collectively, the nerve disorders are responsible for 443 million years of healthy life lost due to illness, disability or premature death, known as disability-adjusted life years (DALYs).

Tension-type headaches (about 2 billion cases) and migraines (about 1.1 billion) are the two most common neurological disorders, while diabetic neuropathy is the fastest-growing one. Painful stinging or burning sensations in the nerves of the hands and feet are often the first symptoms of diabetes.

“The number of people with diabetic neuropathy has more than tripled globally since 1990, rising to 206 million in 2021,” said co-senior author Liane Ong, PhD, from the Institute for Health Metrics and Evaluation at University of Washington. “This is in line with the increase in the global prevalence of diabetes.”

Over 80% of neurological deaths and disability occur in low- and middle-income countries, with western and central sub-Saharan Africa having the highest DALY rates. In contrast, high-income countries in the Asian Pacific and Australasia regions had the lowest rates.

“Nervous system health loss disproportionately impacts many of the poorest countries partly due to the higher prevalence of conditions affecting neonates and children under 5, especially birth-related complications and infections,” said co-author Tarun Dua, MD, Unit Head of WHO’s Brain Health unit.

“Improved infant survival has led to an increase in long-term disability, while limited access to treatment and rehabilitation services is contributing to the much higher proportion of deaths in these countries.”

Medical providers specializing in neurological care are unevenly distributed around the world, with wealthy countries having about 70 times the number of specialists as low-income ones.

Researchers say prevention needs to be a top priority in addressing the growth of neurological conditions. Some disorders, such as stroke and chronic headache, are potentially preventable by lowering risk factors such as high blood pressure, smoking and alcohol use.

The study was funded by the Bill and Melinda Gates Foundation.

Long Covid Linked to Chronic Pain Conditions

By Pat Anson, PNN Editor

People with chronic pain conditions such as fibromyalgia, chronic fatigue, migraine and irritable bowel syndrome are significantly more likely to have symptoms of Long Covid after a COVID-19 infection, according to a large new analysis.

Researchers at the University of Michigan analyzed electronic health records of over two million Americans and found that the risk of having Long Covid symptoms was higher in people with a chronic overlapping pain condition (COPC).  

Over half the patients (58.6%) with a COPC and a diagnosis of COVID-19 had symptoms of Long COVID, compared to only a third (33.6%) of those without a COPC.

“We hypothesized we’d see an increase in pain and fatigue because it’s something we’ve seen in the past with other infectious diseases, like the SARS outbreak in 2002,” said lead author Rachel Bergmans, PhD, a Research Assistant Professor at U-M’s Department of Anesthesiology, Chronic Pain and Fatigue Research Center. “A big predictor of future pain is having had pain in the past.”

Findings from the retrospective cohort study, published in the journal Pain, do not establish a definitive cause that links chronic pain with Long Covid – only an association.

It’s a bit of a chicken-and-egg situation. Many of the symptoms of Long Covid mirror those of COPCs – such as brain fog, chronic fatigue, headache and body pain – so it’s not clear which condition developed first. Interestingly, Long Covid symptoms were found in 24% of patients with a COPC who were not diagnosed with COVID-19.  

That finding could be explained by a relatively new concept in pain research called neuroplasticity or nociplastic pain – chronic pain that lingers and becomes heightened in the brain and central nervous system (CNS) long after the initial injury heals. 

“With nociplastic pain, some people have what you might call a pain setting turned up in their central nervous system. There’s evidence showing that infections, trauma, and stress can be a trigger for nociplastic pain features and related symptoms,” said Bergmans.

Nociplastic pain could also explain the cognitive dysfunction and other symptoms caused by Long Covid – known technically as post-acute sequelae of SARS-CoV-2 infection (PASC). The basket of symptoms now collectively known as Long Covid may have existed before COVID-19 even came along. In 2022, the CDC estimated that 18 million American adults had Long Covid.

“The onset of long COVID features was relatively common regardless of acute COVID exposure. In addition, those with pre-existing COPCs had an increased risk of being diagnosed with long COVID features. These findings reinforce the likelihood that nociplastic pain is a key mechanism in long COVID and can inform precision medicine therapies that avoid the pitfalls of viewing long COVID exclusively in the framework of infectious disease,” researchers concluded.

“For clinicians who treat people with long COVID, it may be helpful to review the medical record and see whether someone had a pre-existing COPC diagnosis before long COVID onset.”

Bergmans and all of her co-authors are either consultants or employees of Tonix Pharmaceuticals, a company that is developing new non-opioid treatments for fibromyalgia.

Migraine Sufferers Rank Triptans as Most Helpful Medication

By Pat Anson, PNN Editor

A large new study that compared the effectiveness of acute migraine medications found that triptans are two to five times more helpful than ibuprofen and acetaminophen in treating migraine attacks. Triptans were also found to be more effective than Excedrin migraine, opioids, and other non-steroidal anti-inflammatory drugs (NSAIDs).

The study used a unique methodology, gathering data on over 3 million migraine attacks reported by over 278,000 people in the US, UK and Canada who used a smartphone app during a six-year period. The Migraine Buddy app allows users to monitor the frequency of their migraine attacks, triggers and symptoms, and rate how “helpful” or “not helpful” their medications are.

“There are many treatment options available to those with migraine. However, there is a lack of head-to-head comparisons of the effectiveness of these treatment options,” said lead author Chia-Chun Chiang, MD, a neurologist who specializes in Headache Medicine and Vascular Neurology at the Mayo Clinic. “These results confirm that triptans should be considered earlier for treating migraine, rather than reserving their use for severe attacks.”

Chiang and his colleagues looked at a total of 25 medications among seven drug classes. Different dosages and medication combinations were combined in their analysis. Newer drugs that inhibit calcitonin gene-related peptides (CGRP) were excluded because they were not in wide enough use during the study period.

How Patients Rated Effectiveness of Acute Migraine Drugs

NEUROLOGY

The study findings, published in the journal Neurology, ranked several triptans (eletriptan, zolmitriptan, sumatriptan, rizatriptan, naratriptan, almotriptan and frovatriptan) as the most helpful medications, with about 75% effectiveness.

By comparison, acetaminophen (paracetamol) was helpful only 37% of the time.

“Our results strongly support the use of triptans, the first class of migraine-specific medication for the acute treatment of migraine,” researchers reported. “In practice, NSAIDs and acetaminophen are generally the first-line medications utilized for mild to moderate headache, and migraine-specific medications are often reserved for moderate to severe migraine attacks, which could potentially result in under-utilization of triptans or delayed treatment during migraine attacks.”

Participants found NSAID’s more effective than acetaminophen, with ketorolac helpful 62% of the time, indomethacin helpful 57% of the time, diclofenac helpful 56% of the time and ibuprofen helpful 42% of the time.

Excedrin migraine was effective only about half the time, about the same as tramadol and codeine. Opioids are usually not recommended for migraine because they’ve been associated with medication overuse headache.

“For people whose acute migraine medication is not working for them, our hope is that this study shows that there are many alternatives that work for migraine, and we encourage people to talk with their doctors about how to treat this painful and debilitating condition,” said Chiang.

Migraine affects about 39 million people in the United States and is the second leading cause of disability worldwide, according to the American Migraine Foundation.  

Another recent study that compared migraine prevention drugs found that two medications usually used to treat depression and high cholesterol are just as effective as the new CGRP inhibitors. Amitriptyline is a tricyclic antidepressant, while simvastatin is a statin. Both drugs are used off-label for migraine prevention and cost substantially less than CGRP drugs.

Cheap Drugs May Prevent Migraine Just as Effectively as Expensive Ones

By Pat Anson, PNN Editor

Two drugs commonly used to treat depression and high cholesterol are just as effective at preventing migraine as CGRP inhibitors, according to a large new study.

They are also a heck of a lot cheaper.  

Researchers at the Norwegian Center for Headache Research analyzed the prescription drug history of over 100,000 migraine patients in Norway from 2010 to 2020. Their goal was to see if patients reduced their use of medications used to treat acute migraine pain – such as triptan – once they started taking drugs used to prevent migraine.

“When the withdrawal of acute migraine medicines changed little after starting preventive medicines, or people stopped quickly on the preventive medicines, the preventive medicine was interpreted as having little effect,” explained lead investigator Marte-Helen Bjørk, MD, a Professor in the Department of Clinical Medicine, University of Bergen.

“If the preventive medicine was used on long, uninterrupted periods, and we saw a decrease in the consumption of acute medicines, we interpreted the preventive medicine as having good effect.”

Beta blockers are often the first drugs used to prevent migraine attacks, but Bjørk and her colleagues found that three other medications were associated with lesser use of triptans: amitriptyline, simvastatin and CGRP inhibitors.

Amitriptyline is a tricyclic antidepressant that is mostly taken for depression, while simvastatin is a statin used to treat high cholesterol. Both drugs are also used off-label for migraine prevention.

CGRP inhibitors are a relatively new class of medication that block calcitonin gene-related peptides, a protein that binds to nerve receptors in the brain and triggers migraine pain. Since 2018, the FDA has approved over half a dozen CGRP medications, which are considered the biggest innovation in migraine treatment in decades.

However, CGRP drugs are not cheap. Eight doses of Nurtec, a tablet taken daily to prevent and treat migraine, can cost over $1,000, while the listed price for Emgality is $679 for a self-injectable syringe used once a month for migraine prevention. Prices will vary for patients, depending on insurance and whether they qualify for a patient assistance program.

By comparison, amitriptyline and simvastatin are screaming bargains. A bottle of 30 simvastatin tablets will cost about $14, while amitriptyline costs about $13 for a supply of 28 tablets.

When it comes to reducing triptan use, amitriptyline, simvastatin and the CGRP inhibitors performed about the same. During the first 90 days of treatment, nearly 57% of patients taking simvastatin reduced their triptan use, compared to 53% of patients taking amitriptyline and 55% of those taking CGRP medicines.

The study findings, recently published in the European Journal of Neurology, show that patients taking beta blockers, topiramate or clonidine were more likely to keep taking triptans.

“Our analysis shows that some established and cheaper medicines can have a similar treatment effect as the more expensive ones. This may be of great significance both for the patient group and Norwegian health care” says Bjørk, who has already started work on a clinical trial to see if other cholesterol-lowering drugs can prevent migraine.

Migraine affects about 1 billion people worldwide and 39 million in the United States, according to the American Migraine Foundation. In addition to headache pain, migraine can cause nausea, blurriness or visual disturbances, and sensitivity to light and sound. Women are three times more likely to suffer from migraines than men.

Childhood Trauma and Neglect Increase Risk of Headache Disorders

By Pat Anson, PNN Editor

People who experience traumatic events during childhood, such as physical abuse, sexual abuse or neglect, are more likely to have headache disorders as adults, according to a large new study. The research adds to a growing body of evidence linking adverse childhood experiences (ACEs) to headaches and migraines in adults.

“Traumatic events in childhood can have serious health implications later in life,” says lead author Catherine Kreatsoulas, PhD, of Harvard T.H. Chan School of Public Health. “Our meta-analysis confirms that childhood traumatic events are important risk factors for headache disorders in adulthood, including migraine, tension headaches, cluster headaches, and chronic or severe headaches. This is a risk factor that we cannot ignore.”

Kreatsoulas and her colleagues reviewed 28 studies that examined the childhood histories of nearly 155,000 people in 19 countries. Their findings are published Neurology, the medical journal of the American Academy of Neurology.

About a third of the participants (31%) reported at least one traumatic childhood event. Of those, 26% were diagnosed with a primary headache disorder, compared to 12% of participants who said they experienced no childhood trauma. People who had four or more traumatic events during childhood were more than twice as likely to have a headache disorder than those who had one ACE.

Researchers also examined different types of childhood trauma. Events categorized as “threat” traumas included physical abuse, sexual abuse, emotional abuse, witnessing or being threatened with violence, and serious family conflicts.

Events categorized as “deprivation” traumas included childhood neglect, economic adversity, divorce or separation, parental death, alcohol or substance abuse, and living in a household where someone has a mental illness, chronic illness, disability or is incarcerated.

Threat traumas were linked to a 46% increase in headache disorders, while deprivation traumas were linked to a 35% increase in headaches. Among threat traumas, physical and sexual abuse were associated with a 60% increased risk for headaches. Among deprivation traumas, neglect was linked to a nearly three-fold increased risk for headache disorders.

“Threat or deprivation traumas are important and independent risk factors for headache disorders in adulthood,” said Kreatsoulas. “Identifying the specific types of childhood experiences may help guide prevention and treatment strategies for one of the leading disabling disorders worldwide. A comprehensive public health plan and clinical intervention strategies are needed to address these underlying traumatic childhood events.”

Due to the stigma and sensitive nature of childhood trauma, researchers say it’s likely the number of ACE cases is under-reported by adults.

 “Despite this, the robustness of these findings cannot be underappreciated as the studies composing this meta-analysis represent diverse global regions and the findings supersede cultural contexts,” they said.

The research does not prove that ACEs cause headaches -- it only shows an association.

Previous studies have also linked childhood trauma to an increased risk of chronic pain conditions such as fibromyalgia and lupus, as well as mood and sleep problems.

Why Living for Others Keeps Me Going

By Mia Maysack, PNN Columnist

While I am “the strong one” that so many look up to and confide in about their hardships and struggles, there aren't many people that I can reach out to in hopes of receiving the same sort of consideration, counsel or support.

I once expressed to a certified professional that one of the main reasons I'm still in existence is for the sake of other people. They looked at me – perplexed -- and proceeded to explain how that was an “unhealthy” approach to life. My reaction was to smirk, because there was obviously no way in hell this individual could begin relating to, let alone understand, what I was saying.

The vast majority of my experiences with therapy have been that the provider and I may as well have been speaking different languages.

Repeatedly, I'm confronted by individuals who say things such as:

“It's my kids who keep me going!”

“I do it all for them! They are my reason for living! I didn't know love or the point of life until I had children!”

I honor all of that to the best of my ability, but also wonder. What’s the difference between that mindset and the point that I made with the therapist?  There isn't one -- other than the fact my motivation doesn't come from having children, but rather from the brokenness of our world as a whole.

What do I mean when I say I live for the sake of others?  It's that I'm equipped with such a deep sense of compassionate empathy that I am able to hold the edges for people who ordinarily do not feel heard or seen. This somehow cultivates the illusion that I'm superhuman, and don’t need to be seen or heard myself.

Just because some of us don't outwardly complain or vent doesn't mean we have it all together, that everything is easy, or that we ourselves aren't drowning in a sea of despair.

Most people wouldn't know how to handle it, if I shared with them the reality of what my life is truly like. They wouldn't know how to respond if I told them that just getting out of bed for me is like running a marathon. Or if I described the pain and torment in my physical body, which keeps me away from things that I want to do and bring me a sense of meaning, joy and purpose.

They certainly don't know how to handle it when the person they depend on reveals that they're beginning to crumble under the weight life has forced them to carry. Anytime that I've attempted to confide in someone, there are three things that occur:

1. They aren't listening to actually hear you, but are simply awaiting their turn to speak -- which usually involves some sort of comparison between your situations, with a hinted suggestion that their situation is far worse than yours.

2. You make them uncomfortable by expressing yourself authentically. They don't know what to do or say, which often translates into doing or saying not much of anything.

3. It causes them major concern and worry, to the point that I then have to reassure the people I sought comfort from that I’m okay.

It has become easier to remain silent. That is why we suffer. That is what’s killing us.

I have zero questions in my mind as to why someone makes the decision to die. That doesn’t mean condoning or promoting it. I simply comprehend the endless reasons why life can be so tiring and how a lifetime of exhaustion can get old -- to the point where someone no longer wishes to go onward.

I believe in everyone's ability to choose and proceed with what's best or right for them, whether I agree or understand it. I've lost countless loved ones and that has been sufficient reason for me not to check out. I can't do it because so-and-so did. I want to carry on so they continue to live through me.

Although I still feel that way most of the time, it needs to be understood how draining it is. Those of us who've managed to cling to an optimistic viewpoint aren't free from our own demons. We slay them daily for the sake of showing up for you and yours.

Mia Maysack lives with chronic migraine, cluster headache and fibromyalgia. She is the founder of Keepin’ Our Heads Up, a Facebook advocacy and support group, and Peace & Love, a wellness and life coaching practice for the chronically ill. 

Woman Files Civil Rights Lawsuit Over Denial of Pain Treatment

By Madora Pennington, PNN Columnist

In September of 2022, millions watched Tara Rule’s emotional video on TikTok, about a doctor who refused to give her a non-narcotic pain medication because it might cause birth defects. The doctor would not even name the drug, even though Rule told him she has no intention of having children because she has Ehler's Danlos syndrome (EDS), a genetic disorder that causes severe health issues.

The 32-year old Rule recently filed a civil rights lawsuit to better establish the illegality of refusing medical treatment to women simply because they are of childbearing age.

Rule’s fight began when neurologist Jonathan Braiman, MD, steered her away from an effective treatment for her agonizing cluster migraines, a common symptom of EDS. According to Yale Medical School, cluster headaches can hurt more than childbirth.

When Rule realized she was being discriminated against by her doctor, she surreptitiously switched on her cell phone to record their discussion, which is legal in New York state. 

Brainman can be heard in the recording asking Rule intrusive questions about her sex life, while ignoring her answers. Rule explained that she was already on a medication that can cause birth defects -- known as teratogenic drug -- and wasn't well enough to have children anyway.

Brainman patronizingly told her she might change her mind if she were to become pregnant. He recommended that she bring in her boyfriend to consent to any treatment that might cause birth defects. Rule left without getting the pain relief she needed for her migraines.

In the parking lot of Albany Medical Center, where the appointment took place, a distraught and tearful Rule made the video and posted it online. Her raw emotion and disturbing story quickly went viral, not only on social media, but in news stories.

In her lawsuit against Braiman and Albany Medical, Rule alleges she was retaliated against by the hospital system. Rule says she was ejected from an unaffiliated urgent care center because Albany Medical had told other hospitals not to treat her. She believes this was a violation of her medical privacy.  

Rule suspects she was blacklisted by other providers in her area. She tried to make an appointment with another neurologist, but was told she was “not an appropriate patient.” Her primary care provider sent a back-dated letter to Rule and her mother saying he was dismissing them as patients. That doctor gave no valid reason for the patient abandonment.

TARA RULE (TIKTOK)

Rule is on disability and lives on less than $1,000 per month. Being banned as a patient is a real hardship.

“Now I have to go to Connecticut to see physicians in a different hospital system. Or travel three and a half hours to New York City. With hotels and gas, it’s very hard. Some of these specialists outside the state are not fully covered by my insurance,” Rule said.

Traveling is made more complicated because Rule can’t stay just anywhere — she needs accessible hotel rooms. And she is accumulating thousands of dollars in debt.

After posting her video, Rule heard from many other patients who have also been discriminated against by their doctors. She felt motivated to find out what legal remedies existed.

With legal guidance, Rule wrote the civil rights complaint herself in what is known as a “federal question” lawsuit, an action that seeks to clarify a constitutional issue in US federal court. Rule has been advised that the medical care she sought does not fall under “conscience protections,” which allow doctors to refuse treatment on religious or moral grounds.  

In preparation for her lawsuit, Rule obtained her medical and insurance records, to help prove that privacy violations occurred. She discovered she had been billed for services not received, and believes her medical records were forged.

Albany Medical did not respond to a request for comment.

Rule’s lawsuit is potentially precedent-setting. It marks the first federal question case against a medical provider for refusing to provide teratogenic drugs because a woman is of “childbearing age.” Refusing to give routine medical care because a patient might get pregnant is discrimination. Patients cannot be forced into unnecessary restraints on their care.

"I am prepared for whatever happens,” says Rule, who is hopeful her lawsuit will help prevent other patients from being discriminated against by their doctors. 

Madora Pennington is the author of the blog LessFlexible.com about her life with Ehlers-Danlos Syndrome. She graduated from UC Berkeley with minors in Journalism and Disability Studies. 

'Growing Pains' in Childhood Linked to Migraine

By Pat Anson, PNN Editor

Did you experience “growing pains” as a child? An unusual ache or throbbing in your legs that occurred late in the day and kept you awake at night?

The Mayo Clinic says there’s no evidence that a growth spell actually causes physical pain, and that any discomfort may be caused by a low pain threshold or even psychological issues.

But a small new study suggests something else may be going on: Brazilian researchers say children who have growing pains are significantly more likely to develop migraines – just as their parents did.  Migraine can be hereditary, and if one or both parents have migraine, there’s a 50-75% chance that their children will also.

“In families of children with growing pains, there is an increased prevalence of other pain syndromes, especially migraine among parents,” wrote lead author Raimundo Pereira Silva-Néto. PhD, a neurology professor at Federal University of Delta do Parnaibal. “Children with migraine have a higher prevalence of growing pains, suggesting a common pathogenesis; therefore, we hypothesized that growing pains in children are a precursor or comorbidity with migraine.”

With parental authorization, Silva-Néto and his colleagues followed 78 children between 5 and 10 years of age, who were born to mothers being treated for migraine at a headache clinic. Their findings were published in the journal Headache.

After five years, about half of the children reported growing pains in their lower limbs. Headaches occurred in 76% of those children, with many meeting the criteria for migraine without aura. By comparison, only 22% of the children who did not have growing pains had headaches.

Lower limb pain was reported most often in the calf muscles (70%), usually lasted more than 30 minutes, and occurred more frequently at night.

That nocturnal connection intrigued the researchers, who noted that previous studies have found that sleepwalking, nightmares, and restless leg syndrome also occur more frequently in children who have migraines.   

“There is no definitive explanation for the nocturnal patterns of growing pains, nor for the overlap with sleep disturbances; however, the authors believe the hypothesis of a common pathogenesis with migraine,” researchers concluded. “Pain in the lower limbs of children and adolescents, commonly referred to as GP (growing pains) by pediatricians and orthopedists, may reflect a precursor/comorbidity with migraine.”

Migraine affects about 39 million people in the United States and is the second leading cause of disability worldwide, according to the American Migraine Foundation. In addition to headache pain, migraine can cause nausea, blurriness or visual disturbances, and sensitivity to light and sound. About one in five teens suffer from migraine.

Head-to-Head Migraine Study Ends in Tie

By Pat Anson, PNN Editor

An unusual head-to-head competition between two migraine prevention drugs has ended in a virtual tie. There were no substantial differences in effectiveness between Emgality and Nurtec, according to preliminary results from a clinical trial released by Eli Lilly, the maker of Emgality.

Emgality and Nurtec both inhibit calcitonin gene-related peptides (CGRP), a protein that causes migraine pain, but their delivery systems are different. Emgality is injected once a month, while Nurtec is an oral medication taken every other day made by Biohaven Pharamceuticals, a subsidiary of Pfizer.

Eli Lilly launched the trial in late 2021, enrolling 575 participants in a Phase 4, double-blind, placebo-controlled study evaluating the efficacy and safety of Emgality (galcanezumab) and Nurtec (rimegepant) for 3 months in adults with episodic migraine.

The so-called CHALLENGE-MIG trial was a bold and somewhat risky move by Lilly, as it seeks to gain more market share in the highly competitive $2 billion U.S. migraine market.

In a statement, Lilly said Emgality did not meet the study's primary goal, which was statistical superiority to Nurtec in achieving at least a 50% reduction in monthly migraine headache days. The response rates of patients and safety profiles of both drugs were similar.

Lilly said Emgality was superior to Nurtec in some secondary outcomes, but didn’t disclose what they were. The company would only say that Emgality helped prevent migraines, as it has in previous studies.  

"These results bolster our knowledge of Emgality's ability to work quickly and help patients improve their quality of life with less frequent dosing," Anne White, executive vice president of Eli Lilly, said in a press release. "Reducing the frequency of migraine headache days can help people experience more freedom from the burden of this debilitating neurological disease and get back to participating in the daily activities that matter most to them."

Final result from the CHALLENGE-MIG trial won’t be posted until later this year.

“Nurtec ODT is the first and only medication approved as both an acute treatment for migraine and a preventive treatment for episodic migraine in adults. It offers flexibility to patients in treating their migraines and is the leading prescribed oral CGRP receptor antagonist,” Pfizer said in a statement. “We are confident in the efficacy and tolerability profile of Nurtec ODT as demonstrated in the clinical trials and the well-established patient preference for oral agents over injectables.

First approved by the FDA in 2018, CGRP inhibitors are the biggest innovation in migraine treatment in decades. They are also expensive, whether taken by pill or injection.

The listed cash price for Emgality is $679 for a single injection or $8,148 annually; while 8 tablets of Nurtec cost $1,011 or about $23,000 a year. Costs to patients will vary, depending on insurance coverage, copay assistance programs and rebates.

I’m Already Well Aware

By Mia Maysack, PNN Columnist

If I did not cling to my optimism for dear life, I'd scoff at the concept of an awareness month such as June being nationally recognized as Migraine & Headache Awareness Month.

That’s due to the fact I am someone who has lived with a daily reminder of intractable pain for over two decades. It isn’t those of us who can directly relate to the pain experience that are in need of awareness.

I feel many “awareness” efforts are limited or fall short in terms of gaining recognition for a specific cause or reason. People typically don’t concern themselves with issues that don’t directly affect or impact them.

Someone who hasn’t ever had a migraine couldn’t possibly understand how it differs from a regular stress headache. Furthermore, somebody who does experience an occasional migraine still cannot fathom what it would be like to have one on a more constant basis.

What transpires within and throughout our individual lenses of the world is real to us and valid, though different from others. That doesn’t lessen the next person’s experience as being anything less than our own.    

There have been some who have thought of my claims about illness are disingenuous. But the reality is that I actually learned to “fake” wellness, in an effort to create a sense of fulfillment and meaning in my life, despite the hand I’ve been dealt.

Others claim those of us who live with pain should be able to “fix” ourselves, once we acknowledge things like a childhood trauma; or that if we adopt “sufficient water intake” and “sleep hygiene” for example, all will be well.

Although I believe there’s some merit to those suggestions, and that they come from a decent, well-meaning place --- if it were that simple, I would be healed by now, along with millions of others who endure similar circumstances.

For a lot of us, we’ve had to come to terms with the fact that there may not be anything out there to give us back the life we once had or wanted. That’s because we’ve already attempted and tried just about everything in search of pain management or relief.

Often, we’re unable to obtain access to options that might ease our suffering because that process can be a grueling one and often has a ripple effect of further complications, along with a multitude of hoop jumping. That’s why I’ve mostly refrained from making it a habit to ask for professional help. Instead, I have worked on acceptance, as there are not many things that anyone else can do for me.   

Relentless and untreatable ailments in any form are going to take a toll, but I hold steady to the concept of “pain” being a worldwide experience that each and every one of us can relate to in some way or another. Each of us have had moments when we’d do just about anything to have the discomfort end.

But instead of embracing the potential for common ground, we as a society tend to label people, when the cure is to be found in seeing and treating one another as fellow human beings. We never truly know where a person may be in regards to their mental health or quality of life, and need not make this already challenging existence any more difficult for ourselves or each other.

Given the extent I’ve witnessed how our healthcare system fails us, I had to choose to not identify with the victim mentality or wait any longer for answers elsewhere.  Ultimately, I stumbled upon empowerment in owning my situation, by tending to myself in ways that I am able. That was my education in self-awareness.

Mia Maysack lives with chronic migraine, cluster headache and fibromyalgia. She is the founder of Keepin’ Our Heads Up, a Facebook advocacy and support group, and Peace & Love, a wellness and life coaching practice for the chronically ill.