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Overview of Migraine Acute Migraine Treatments
characteristics of migraine Office Migraine Rescue Treatments
Optimum Migraine Care Migraine Prevention Overview
Common Migraine Treatment Mistakes Oral Migraine Preventives
What doctors treat migraines? Procedures to Prevent Migraines
Migraines and Pregnancy Monocolonal Antibodies
Childhood and Pediatric Migraines Devices for Migraine Treatment and Prevention

Office Based Migraine Preventative Procedures

Dr. Loftus is the only headache practice that offers office procedures and IV rescue therapy in his office. The rescue therapies are only offered to existing patients. They allow an existing patient to call the office any morning and receive rescue therapy the same day at our office. This will make the need to go to an ER much less likely. In addition, this allows for therapeutic interventions between normally scheduled office visits should the patient find themselves not doing as well as expected. All of these treatments are highly cost effective. Coverage varies by insurance and will be discussed for each of the options given.

Dr. Loftus also offers a wide variety of office based migraine procedures. Except for Botox® treatment for chronic migraine, usually only these procedures are only offered by Board certified headache physicians. Anesthetia pain physicians tend to offer different types of procedures for migraine headache.

Botox® (onabotulinum) brand botulinum toxin for prevention of migraine

The most commonly found office migraine procedure in general neurologist offices for migraine prevention is the use of Botox® for chronic migraine. Prior to the release of the Monoclonal Antibodies against CGRP (MAAC) or its receptor (MAACR), Botox® was the only FDA approved for the prevention of headaches in patients with chronic migraine. Because it is one of the more expensive therapies for migraine prevention, it is generally used after patients fail multiple oral therapies.  Also, because of its cost Dr. Loftus feels it is essential for patients to keep a headache diary with disability information.  This allows one to determine that the treatment is clearly helpful as well as provide an early warning when the medication is wearing off. The cost is about $500 per month.

Although there is some debate as to the best way to utilize Botox®, Dr. Loftus always begins his Botox® patients with the FDA approved 31 injection paradigm. The treatment algorithm is repeated every 84 days. In general, one does two or three cycles in order to determine if there appears to be an adequate response to continue to use this treatment. The good news about Botox® for chronic migraine prevention, is that all of the side effects wear off. The medication has been in use for more than 25 years and so the long term safety is well established. In the short term, the most common side effect of this treatment is transient weakness or pain in the neck. If this occurs, then a lower dose is given in the neck for subsequent cycles. Another issue with Botox® treatment is that it does not always last 12 weeks. When it does not last long enough, then Zytaze® is recommend to use in future cycles. Zytaze is designed to increase the level of zinc in the tissues and zinc is a necessary cofactor for all botulinum toxins to work. Although not studied for wearing off during migraine, in well controlled studies of other diseases, it lengthens the effectiveness of Botox® by 30%. Dr. Loftus does not use it routinely as it may increase the risk of neck weakness. On average, those that received Botox had about a 7 fewer headache days after a couple of treatment cycles. They continued to improve during the open label phase.

As the cost of Botox is about $500 per month, patients generally have to fail 2 or 3 prior treatments from different classes to get insurance coverage. It is generally covered only for chronic migraine and not for migraines with less than 15 headache days per month. Botox® can be used during breast feeding.

Sphenopalatine Ganglion (SPG) block

According to an article about Sphenopalatine Ganglion Block published in 1993, the earliest use of this technique goes back to 1908. Until relatively recently, it was most commonly performed with a long needle under radiographic guidance. More recently, there has been the development of multiple devices to allow for routine placement of SPG block in the physicians office. The Allevio and Sphenocath devices are almost identical. The Tx360 device is very different. Although the Tx360 device is much easier to perform, it appears to Dr. Loftus that the Allevio device is more effective - at least for single use. The Allevio device is used for both acute migraine treatment (rescue) and for preventative treatment. With the patient lying back on a massage tablet with the head tilted back, the device is placed in the nose. Lidocaine is injected to achieve the block. The patient's eyes generally water and the blood flow to the cheeks generally increase but the mechanism of these changes and its importance is not clear. It appears that acute headaches get better about 80-90% of the time and a 1-2 week prevention occurs about 30% of the time. There is limited controlled data at this time. Some insurances pay for this therapy and some do not. The cost of this treatment at Bellaire Neurology is $300. When it works well for prevention, repeated use generally allows the blocks to be 2-3 months apart. Lidocaine usage is safe during pregnancy and breast feeding so it is commonly used in this time frame.

For those that do not have access to get an office based SPG block or for those who have used it at the office successfully but want to try and do it at home, Dr. Morris Maizels has kindly contributed his method for SPG block at home with viscous lidocaine.

There are many different nerve block procedures used by different physicians to treat frequent and chronic migraine. The fact that they can work at times does not prove that the migraine is being triggered by various injuries to the nerve. Dr. Loftus prefers a technique made popular by Dr. Kaniecki that includes blocking branches of both the trigeminal nerve and occipital nerves. A review of chronic migraine patients in my practice indicates that about 50% of patients get good benefit from the block and the blocks, when they do work, last 12 weeks 75% of the time. Coverage by insurance varies widely. The cost of this treatment at Bellaire Neurology is $300. It is therefore about 20% of the cost of the Botox® therapy or the newer monoclonal antibody treatments that affect CGRP (MAAC and MAACR). The blocks are typically done with bupivacaine but during early pregnancy, lidocaine 2% is usually used as lidocaine is considered safe for pregnancy and bupivacaine safety is less known. Given the extremely low systemic blood levels from any block (less than 4 cc total of bupivacaine 0.25% of 0.5%) and metabolism of the drug by the liver, it is unlikely a fetus sees any of the medication. These blocks can also be used during breastfeeding.

The most common type of occipital nerve blocks used by neurologists is different in that only 2 injections occur on each side of the back of the head to try and achieve an occipital nerve block. Steroids are commonly used. These blocks do not appear to be as useful for preventative therapy.

IV Magnesium

For prevention, IV magnesium 1 gram in 50 cc given over 5-6 minutes weekly appears to be an excellent preventative therapy. Controlled studies are lacking. For those that find it useful, giving the medication relatively quickly instead of over an hour or more - seems to make it work better. Without controlled studies, no one really knows its absolute effectiveness. When it does work, then most patients do fine with every other week treatment. Some physicians believe the medication is only needed monthly but this has not been Dr. Loftus' experience. There has been extensive use of IV magnesium as much higher doses in pregnant women during the 3rd trimester. There is less use of IV magnesium earlier in pregnancy. The most common side effect is feeling warm and flush for a few minutes. For those that have the capability to receive this treatment at home or work, it is frequently used early in prevention. For those that are dependent on coming to my office for its use, it tends to be used more for pregnancy, post-concussive headache, and as a bridge therapy to other preventatives. Dr. Loftus' currently charges $105 per dose.