Chronic Pain Chronicles with Dr Karmy
Join Dr. Grigory Karmy M.D., a distinguished chronic pain management physician with over 20 years of experience, on a captivating journey through the world of pain relief in his podcast series. Delving into the latest regenerative medical treatments like PRP, stem cell injections, and prolozone therapy, alongside educational discussions on pain transmission and the latest medical innovations, Dr. Karmy shares invaluable insights and real-life stories, empowering listeners to find relief and regain control over their chronic pain.
Chronic Pain Chronicles with Dr Karmy
Episode 19: New Treatments for Headaches
Send us a text with your thoughts on this episode!
Join Dr. Karmy for an interview with Dr. Warren Goldstein, a neurologist with extensive experience in headache management.
In this episode, we will have an in-depth discussion about a new class of migraine medications that block CGRP neuropeptides. Are the risks worth the benefits? What about insurance coverage?
Should you try this new class of medications? Find out.
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This has been a big boon for migraine patients worldwide because these medications are extremely effective. Uh. And have very low side effect profile. They do in one way or another target, CGRP. Hi this is Dr. Karmy for Chronic Pain Chronicles, and today with us we have Dr. Warren Goldstein. Dr. Goldstein is a neurologist with over 20 years of experience. And the reason we have him here today is because I wanted to discuss migraines and I'll walk pain clinics do see a fair number of headaches. The most common type of specialist that sees headaches in Canada is a neurologist. Dr. Goldstein has a very unique experience. In this field because in addition to practicing in Canada, he also has some training in headache management from Israel. So he's able to compare and contrast how this condition is managed in different countries. Hello, Dr. Goldstein. Hello, Dr. Karmy. How are you today? Fine. Thank you for joining us. Let's maybe start by just talking a little bit about causes for migraines. There is, I some ideas as to what causes other forms of chronic pain. Typically, the discussion centers about central sensitization where the part of the nervous system that responsible for perceiving pain becomes hypersensitive and sends pain signals from tissues that I have healed and are no longer damaged. But migraine is a little bit different. It's a little bit unique. Can you just make a few comments about how scientists think about the causes for migraines? Sure. So migraine is a condition some people would call it a disease. I think a better word is a condition. You are born with this condition. It is genetically inherited. It's not through one gene. It's through polygenic inheritance. Many different genes are involved, but some people are migrainers people that get episodes of migraine and have migraine, and some people aren't. That's on the basis of genetics. Now, people who are migrainers who have this condition migraine, it's similar to, let's say by analogy, asthma. Okay? Asthma is a condition disease that only some people have and they're episodes all the time, but they get episodes of asthma that can be triggered by certain things. So they, they have an underlying condition, asthma, and it gets triggered by certain things. And the same is true in migraine. The episodes of migraine get triggered. Very often we cannot recognize what the triggers are. These episodes come and go at different times for no known reasons. However, we are aware of many things that will trigger migraine. Hormones are a very potent trigger. So migraine is actually more common in women than men around twice as common in women and men and a typical pattern is that women will get episodes of migraine with their menstrual periods. Starts at Menarchy when they start beginning in their period is when they get their first migraine. It often changes that goes away during pregnancy and can be aggravated by the birth control pill and will often go away with menopause. That's a very common pattern, but sometimes we see exact opposites that women don't get their first migraine until the menopause, for example. So migraines are a trigger. Certain foods and drinks. Can be triggered, particularly foods that contain nitrates, like deli meats. Cheese, particularly old cheese can be a trigger. Certain forms of alcohol such as red wine can be a trigger. Citrus fruit can be a trigger. So there are things we eat and drink that can trigger migraine. And another environmental trigger, very interesting enough is weather often a drop in the blood pressure, sorry, in the air pressure before a storm will trigger migraine. And we hear this all the time from ERs saying that they know that there's a storm coming because they're starting to get their migraine and exactly what the mechanism of that is, is not known. But that's a trigger. Poor sleep can be a trigger. Stress can be a trigger. So these things trigger the episodes. They don't cause the condition, they trigger the episodes. I guess in the context of pain clinics, what I see a lot of is patients who develop migraine, a condition after a trauma of some kind, like a car accident, a whiplash where they will have headaches that would qualify for diagnosis of chronic migraines. Often they are, often your typical migraine. Yeah, said around menstrual period of time, maybe a couple of times a month worse. Patients after trauma will often have headaches that are there almost every day. Is this the same condition? That's an interesting question. Certainly I see that very often too, patients after a whiplash or after a mild traumatic brain injury, a concussion will get headaches that we classify officially as post-traumatic headache. But I agree with you. Many of them look just like migraine, in which case we would describe them as a post-traumatic headache with a migraine phenotype. It looks like migraine. Now is it, or is it not the same condition? I don't know. It's a debate. My feeling is that these people probably do have some genes that predispose them to getting migraine, but it's never manifested in their lifetime until there's been a major stress and this uncovers it. That's my belief. Which brings me to my next question . If you have somebody with post traumatic headache with features of a migraine, would one, treat it the same way with some of the same medications that one would treat migraine with, or would one approach that person, a patient differently? So my approach would be to treat it, this is not just in this situation, but we many times see, patients with a symptom complex that doesn't seem to fit exactly into one of our diagnostic categories, but it resembles something that we've seen before. For example, patients who have pain in many different parts of their body and resemble patients with fibromyalgia, but they're not a clear diagnostic case of fibromyalgia in case. Like that I would treat a patient the way I would treat a patient with fibromyalgia because they have something, looks like it, it works in that condition. That's what I would do. So the same with these patients. If it looks like migraine, I'm gonna approach it the same way that I would approach somebody with migraine. Okay. So let's move on to talking a little bit about some of the treatment options for migraines. Of course, most of the medications that we use for migraine management are very old. Many of them have been around for 50, 60 years. Yeah. So we're moving on to talking about treatments of migraine. Of course a lot of medications that we use for migraine management are very old. But recently there has been a brand new class of medications that came out on the market. That's totally different and totally unrelated to anything that has been used before. And primarily what these medications do is block neuro peptide called CGRP, calcitonin Gene Related Peptide, which has a very important role in migraines. Can you talk a little bit about some of these newer medications? Sure. This has been a big boon for migraine patients worldwide because these medications are extremely effective. Uh. And have very low side effect profile. They do in one way or another target, CGRP, which I can talk about afterwards if you like. But these medications, the first number that we had, which we've had for several years, I'm not sure, 10 years, let's say. Were all injectable medications. They were antibodies against either the CGRP receptor or the CGRP molecule itself. And these are monoclonal antibodies and they were extremely helpful in in reducing the frequency of migraine with a very low side effect profile. One of the big issues with these medicines is they're expensive. That's often a barrier to patients getting them if they don't have the appropriate insurance. But they're very effective and they have in my opinion, negligible side effects. They can have injection site reaction. Some patients have had constipation with it. We were concerned because many of the medications we've used over the years with migraine are vasoconstrictors. They narrow arteries. We were concerned that this could be a danger in patients who already had narrowed arteries, let's say, in patients who had heart disease, coronary artery disease or stroke. But we found that this risk is minimal, that in the real world we're really not aware that these drugs cause stroke or heart attack. And we, we use them in people with these risk factors, with these illnesses. We might be hesitant to use them in the first two or three months after a stroke or after a heart attack, but otherwise we haven't seen problems with it. Another condition in which people have vasoconstriction narrow arteries is Raynauds phenomenon where the arteries in the fingers will get narrow to the point that fingers will not get any blood. They'll turn colors, including white and go cold. And this happens in certain diseases, and we know that these medications can aggravate that condition in general. We try to avoid it in patients with that condition, but we've seen very little in the way of side effects with these medications and very high efficacy. So those are what I said were the ones we've had for 10 or years or so. It's just my guesstimate, how long but just in the last couple of years now we have something similar, but they are oral medications and also with a very low side effect profile and very high efficacy. So what about pregnancy? Yeah, so that's an excellent question because that is a big concern. With all of our medications, we're always thinking about what if the patient, is the patient gonna get pregnant? What if the patient gets pregnant? Which medications are safe in pregnancy? So the ones that we've had for several years that are the injectable antibodies against the CGRP receptor. First of all, none of these drugs, the new ones that are oral or the ones for the the CGRP receptor injectable antibodies were tested in pregnancy. Okay. So there's a reason not to use it in pregnancy. But secondly, we have reason to believe that they might not be safe in pregnancy even though they weren't tested in pregnancy. So the injectable ones, the ones that we've had for a few years, the monoclonal antibodies. The problem with these ones is they have a very long half-life. Most of those drugs only need to be injected once a month because they have a half-life of about a month. And therefore if we start someone on it , and then after their first injection they tell us that they're pregnant, that drug is going to stay in the body five or six months because we consider it cleared after about five or six half lives, so five or six months. So those medicines we don't prescribe in women with a high chance of pregnancy, those who are having unprotected sex with no form of contraception. And we counsel patients that, you have to commit to not getting pregnant for six months after you start the drug. What's different with the new drugs, the oral ones? We have one oral preventive. A drug called Qulipta that is useful for migraine prevention in Canada. There is another one that's not approved for that yet in Canada, but is approved for it in the United States. And the thing about that drug is that it's got a much shorter half-life in the order of hours, like 12 hours. So basically, even though we know it's not safe in pregnancy we will use it in women where there's a chance of pregnancy as long as they understand that there's a slight risk and that as soon as they become pregnant. They have to go off it. That's a bit unofficial. I don't think if you read the drug monograph, they would tell you to do that. This is the way it's being used in the headache world, that if you need a drug to go on and you understand there's a slight risk in pregnancy, but not very much because it's such a short half life, we can stop it quickly. We will use it in that population of women. And for all of these women, we always recommend going on some dosage of folic acid to protect the developing fetus, the dose is debatable. Some some say one milligram, two milligrams, some say five milligrams. I tend to use five milligrams. So it sounds like generally speaking, they're not safe in pregnancy, but for some of them, the duration of time for these medications to wash out is much longer up to seven months. And for others it is much shorter. Yeah. But are not recommended to be used in pregnant women. Yeah. So what about the effectiveness? What. And percent, and perhaps it differs from one medication to another. But what percent of the time will patients respond to these medications that act on CGRP pathway? Yeah. Yeah. So just to make it very simple, an approximation, okay. For most of them, they work in about 50% of people. And for about 50% of the people, they'll get about a 50% reduction in the frequency of their migraine episodes of the new medications, roughly speaking. Okay. And what happens if one belongs to that 50% that didn't respond? Is it worthwhile trying? Okay, so first all, there's two subcategories as you mentioned. There's one subcategory which actually targets CGR Neuro Peptide itself, and there's a second subcategory which targets the receptor for CGR Neuro Peptide. So yeah, you tried one of those medications and it didn't work. Is there any value in trying a different medication that targets one of these two things? Yeah. Yeah. The answer is yes. I believe that you need to try something. You could even try one that had the same mechanism of action. But I agree with you. The sensible thing would be to consider trying one that had the slightly different mechanism of action. Okay. I guess at what point, would you give up? If you try two medications that work on this particular pathway, would you try a third? I think we never give up. I think that's what we, as opposed to in the chronic pain world do. Right? Yeah. As opposed to moving on to some of the other migraine medications that work not through CGRP pathway but through a different pathway. It's an interesting question. These things are relatively new to us and the other drugs that we've had for years and years. In fact, we don't exactly understand how many of them work but they don't work directly through CGRP as I, I believe, before we have these new drugs, the new antibodies against the CGRP. Up until that time, all of the drugs that we used for preventing migraine weren't developed for prevention of migraine. They were developed for other conditions such as epilepsy depression, high blood pressure, and were found to work in migraine. And then they were studied and they worked in migraine. So exactly how each one works in migraine is a bit of a debate. Theoretically the answer to your question is yes, but from a practical point of view, most of these patients have been through all of those already or some of those already because they are covered by their insurance. They're less expensive. And those drugs, have a much lower efficacy in general. Theoretically if they haven't been tried on some of those, you would do that. I would quite often, I will go with combinations. A patient, if they had some benefit on one of the older drugs, but it wasn't a great benefit, I wouldn't stop the older drug and I would add the new one and in this case where they haven't been on the older ones and they were just on the new one and it wasn't working. If it was working a bit, I would probably keep it and add one of the older ones. So it's a bit of an art. I can't really say there's a set answer to that question, but yes, you would consider what else is in your quiver and what else could you possibly add to the mix? Or instead? Let's go maybe to the other extreme. Let's suppose you have a very strong response and the headaches completely go away. After how long would you consider stopping the migraine medications? What if you would consider stopping the migraine medications? I would maybe have a discussion with the patient at a year and if migraine was very significantly bothersome and disabling to them, and suddenly we have excellent control I wouldn't be anxious to stop the medication, but I wouldn't bring it up myself for a year. But if the patient brings it up, then, we'd have a discussion. A lot of patients just don't like the idea of being on medication. So they say, doctor, could I please come off? I don't really want to be on medication. Do I really need to be on it? And I would answer that by saying we don't know. We could try if you like, or we could leave well enough alone. And if they didn't bring it up to me, I would probably leave well enough alone. I guess you mentioned coverage of these medications. And from what I understand the insurance companies, most of them will not cover these medications right off the bat, uh, because of the expense. Typically there's a number of hoops one has to jump through in order to qualify. One can qualify. What has your experience been in terms of coverage? Yes. So for the most part we're seeing a pattern in coverage where almost no insurance company is covering these unless the patient has tried two different medications two different families. So in one anti-convulsant. And one antidepressant. And usually they want a period of time of around three months in that ballpark or they want to hear that the patient had to come off it for side effects. But if they failed two medication, two different families, that's when most of the private insurers are coming through. And similar with government insurance is similar just by government you mean? ODSP and over 65? Yes. Yeah. Well just I'm just thinking back to your question about nothing worked to give up or what are you gonna do and I guess there's two, two things we didn't discuss. There's different ways of categorizing migraine with auraura, migraine without aura. The treatment doesn't really change between those two. But then there's another way of categorizing migraine between episodic migraine and chronic migraine and there's nothing biological that gave it this magic number of 15 days a month puts you in the category of chronic migraine, and 14 days a month or less puts you in the category of episodic migraine. So one additional treatment that we didn't discuss is not useful in episodic migraine, but it is useful in chronic migraine, and that is botulinum toxin or Botox. So Botox is a very good treatment for chronic migraine, as effective as the ones we just spoke about. And also very low side effect. And then another thing that we didn't talk about is nerve blocks, because there's some evidence that nerve blocks in the head and neck area, basically targeting branches of the trigeminal nerve. That this can play a role in reducing the frequency of migraine. So very often this could be considered as a complimentary treatment. So what are my final thoughts? First of all, let me make clear that I cheated a little bit and instead of going out and finding an outside guest to speak about the topic, I have chosen somebody that works in my Northyork clinic, and that is mostly because I felt he was a good speaker and he's very experienced in the field. Second, I don't want to leave you with the impression that if you have migraine headache, you should run out and try these medications. If your headache is mild, I. Or it is well controlled with your existing migraine medications. There's absolutely no reason to try these new ones. As per Dr. Goldstein, only about half the people who try them respond and there is a possibility of side effects of be it minor ones. As I mentioned, there are two types of flavors of these medications. There are CGRP blockers that are there for patients who get one or two headaches per month. And then there's the second type of CGRP blockers that are better suited for patients who have headaches all the time or almost all of the time. Who are, the people who I think should go out and try these medications, I think that patients who haven't tried anything new in the last five or six years, um, patients who have persistent, severe or debilitating headaches. Uh, they are the people who should give this medication a try as per Dr. Goldstein interview. Sometimes it's even worth trying more than one of these medications to see if you can find the one that works. Thank you.
