Dr. Robbins Says….

Several new triptans (Imitrex-type meds) have come on the market in the past year and a half;  Axert (almotriptan) came out 1.5 years ago, and more recently Frova.  There are pluses and minuses to each.

Axert is relatively mild, with very few chest symptoms;  it is well tolerated, but does not always pack the impact (work as well) as Imitrex.  Frova is longer-lasting, with a half-life of 26 hours, which can be both good and bad.  I will explain more about Frova later.  Frova is mild, takes longer (up to 2 hours) to work, and is good for longer-developing,  slower onset, more moderate migraines.

A recent study investigated this important subject;  even if a headache med. works, nobody is happy if they gain 30lb.  Surprisingly, Prozac topped the list of weight gainers;  even more than the tricyclic nortryptylline.  Depakote did, as we know, cause weight gain, but less than Prozac.  Topomax (topiramate) was the only one to cause weight loss.  In utilizing headache meds, we are always trying to avoid side effects, and weight gain is a primary one.

Depakote ER, Extended Release tablets, are now available in 250mg tablets, as well as 500. 500mg of the ER is approx. equal to 400 of the regular Depakote, but is longer-lasting. The 250mg tabls help with flexibility in dosing.

The cost of Botox, unfortunately, just went up.. from about $390 per 100unit vial to approx $417 a vial.

The cost of Botox does limit it’s use;  the average patient now recieves 50 to 100 units per treatment.  In the earlier days, we used lower doses.  I do think Botox has a role to play in migraine, CDH, and clusters, but the role is still being worked out.

Novartis Pharmaceuticals announced Dec. 2002 that Sansert (methysergide) is no longer going to be available in the United States.  This will create problems for those who have found that the only preventative med that is effective is Sansert.  With most discontinued meds, such as certain types of Cafergot/ergotamine, the compounding pharmacists are able to make up the med.  However, this will not be possible to do with Sansert.  We will need to search for alternatives, and there are a number of alternatives.

I will be discussing this important subject quite a bit in the next few months.  In addition, we will have a lot on the very important subject ‘What to do when Nothing works’.  Long-acting opioids (Kadian, methadone, oxycontin, MS Contin, Duragesic patch) sustain relief, for at least 6 months, in about 17% of patients put on them.  For those patients, they can greatly enhance quality of life and functioning.  While 17% may not seem too high, it is actually not bad considering that, in this population of headache sufferers, basically nothing else has ever helped.  L.Robbins