Nina Riggins, MD, PhD

“There is promise that if we would change the rate of administration in some cases, maybe from the beginning, we don’t have to observe any of the side effects because they’re not there.”

Dihydroergotamine (DHE) has been used in the treatment of migraine for quite a long period of time, and in recent years, the interest in attempting to optimize this oft used but somewhat unchanged therapy has increased.

One such attempt was conducted by Nina Riggins, MD, PhD, headache specialist, University of California San Francisco, and colleagues, the findings from which were accepted to be presented the 

American Academy of Neurology (AAN) 2020 Annual Meeting

. Their data, which assessed the impact of the infusion rate of intravenous DHE—in either 60 minutes or 90 to 120 minutes&mdash;on inpatient treatment outcomes, suggest that prolonging the infusion time to manage cramping led to an improvement of adverse effects without interfering with efficacy.

To find out more about the study and what the main takeaways are for the clinical community, 

reached out to Riggins for an interview. She provided her insight into the data, what research still needs to be done, and how intravenous DHE is being utilized now.

Riggins N, Ehrlich A, Corroo J, et al. Effect of Dihydroergotamine Infusion Rate on Inpatient Headache Treatment Outcomes. 

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The headache specialist at UCSF discussed the findings of a retrospective assessment of the impact of the infusion rate of dihydroergotamine (DHE) on inpatient treatment outcomes.

Nina Riggins, MD, PhD: The Effect of Dihydroergotamine Infusion Rates

“Right now, in our center we administer 2 rounds of Botox and if patients report no significant improvement, in most of the cases 100 hours or more per month, we are moving onto different treatments. This study might be helpful for the people with moderate to severe cranial autonomic symptoms, if they get another ounce of Botox, they might improve too.”

At the 2019 American Academy of Neurology (AAN) Annual Meeting held in Philadelphia, Pennsylvania, Nina Riggins, MD, PhD, assistant professor and neurologist at the University of California San Francisco, and colleagues, presented findings from a chart review and survey of patients to determine whether the presence of cranial autonomic symptoms (CAS) predict headache benefit from Botox in adults with chronic migraine.

Among the 93 patients enrolled in the study, 9 subjects had no CAS at baseline, 34 subjects had mild symptoms at baseline, and 42 had moderate or severe symptoms at baseline. Investigators reported that 85 subjects had at least 2 rounds of Botox.

Of the subjects with mild CAS, 10 had a 50% or more reduction in headache frequency, of the 42 with moderate or severe CAS and 9 had a 50% or more reduction in headache frequency. Investigators reported that 37 of the 85 participants (39.78%) reported improvement in their CAS intensity.

This finding shows that patients without CAS were more likely to improve from treatment of Botox and those with moderate or severe CAS were less likely to respond to treatment. The investigators reported that Botox could improve CAS after multiple rounds, however, additional studies are needed to explore this finding.

spoke with Riggins in an interview at AAN.

Riggins N, Ehrlich A, Dapkus L, et al. Does the presence of Cranial Autonomic Symptoms in Chronic Migraine Patients Predict Efficacy of Botox Injections? Presented at: American Academy of Neurology 2019, Philadelphia, PA, May 4—10, 2019.

The assistant professor and neurologist at the University of California San Francisco discussed how the presence of cranial autonomic symptoms (CAS) can be a predictor of the effect of Botox on chronic migraine.

Nina Riggins, MD, PhD: Predicting Outcomes of Botox Treatment in Chronic Migraine

Dr Moawad is a neurologist and Clinical Assistant Professor at Case Western Reserve University and John Carroll University in Cleveland, OH, where she teaches undergraduate and medical students. 

She reports no conflicts of interest regarding the subject matter of this article. 

In this podcast, Dr Heidi Moawad interviews Nina Riggins, MD, PhD, a neurologist and researcher at the 

, San Francisco, CA. Dr Riggins discusses new, available treatments in headache medicine, including ongoing research about topical applications and other modes of treatment.

Heidi Moawad, MD (HM): You have done research about symptoms that predict necessity to repeat botulinum toxin injections. Can you describe any surprises? 

 Our study (currently in press) objectives were to determine whether the presence of 

 (CAS) can be a predictor of the effect of botulinum toxin injections on headache and whether the injections improve CAS in patients with chronic migraine.

In addition to a chart review, a survey was administered to current botulinum toxin patients at their visits to the UCSF Headache Center. Survey included questions on CAS such as redness of the white part of the eye, tearing from the eye, nasal congestion, runny nose, swelling around the eye, facial sweating, flushing, pupil looking smaller than usual, ear fullness.

Of the 93 patients enrolled in the study, 85 had at least 2 rounds of botulinum toxin and were included in the data analysis. Patients without CAS were more likely to improve from the treatment for chronic migraine, independently of medication overuse headache. Participants with moderate or severe CAS at baseline were less likely to respond to treatment

 could improve CAS and as symptoms improve, the efficacy of the drug could continue to improve after multiple rounds. Future studies need to explore whether patients with moderate to severe CAS would require more rounds of botulinum toxin in order to show improvement.

HM: When should neurologists anticipate hearing more about results of your study?

The study (with Peter Goadsby, PhD) is in press, and the poster, “Does the Presence of Cranial Autonomic Symptoms in Chronic Migraine Patients Predict Efficacy of Botox Injections?”, was submitted to the 2019 AAN Meeting in Philadelphia.

You are currently doing research about topical applications for migraine prevention. Which medications do you use and where do you place them?

Topical applications are done with anesthetic medications, such as lidocaine, bupivacaine, and ropivacaine. These medications are delivered by a Sphenocath®, an FDA-cleared device, to the region of 

 (SPG). The device does not have a needle and could be described as flexible catheter. A non-invasive procedure known as an SPG block places one of three different anesthetics under the study (lidocaine, bupivacaine, ropivacaine) into the nasal cavity and diffuses to the target in order to block the SPG nerve.

The SPG is located in the pterygopalatine fossa and has multiple connections to facial, trigeminal, parasympathetic, and sympathetic systems which make it a promising target for migraine treatment. SPG blocks are quite commonly performed at the headache center at UCSF to treat chronic migraine, and patients have reported significant relief.

 Scientific Meeting in 2018 titled “Preventive Effects of SPG Blocks in Chronic Migraine Patients Increases With Number of Repeated Blocks.” It was a chart review study that concluded that the SPG block is a safe and effective preventive treatment in chronic migraine. It helped to reduce use of acute (as needed) headache medications in 18 out of 20 patients who received 4 or more SPG blocks with lidocaine.

We would like to determine if the frequency and medications that we use as our standard of care in the clinic prove to be significantly better than placebo and also to see if there is a difference in the anesthetics we use. We submitted the study to the IRB (Institutional Review Board) and received approval for the SPG block randomized placebo-controlled trial.

1. To determine whether SPG blocks can be effective in migraine headache prevention at a lower frequency of administration than in previous studies.

2. To determine if there is a difference in efficacy between lidocaine, bupivacaine, and ropivacaine.

3. To determine whether the repeated use of SPG blocks every 2 to 4 months for 3 treatments will have a cumulative effect, with subsequent treatments providing better and longer lasting effects on headache frequency and severity.

4. To determine if repetitive SPG blocks can reduce the need and use of acute treatments and emergency room visits

Is there a certain patient subtype that is more likely to respond to treatment?

 There is a possibility that patients with 

 could greatly benefit from this procedure. We noted that the SPG block was the treatment that broke the daily cycle of pain for the patients in this group. Whether it is statistically significant needs to be determined by the future studies.

You mentioned a bad taste as an adverse effect of the procedure. How long does it last? 

Bad taste usually resolves within a few minutes, up to an hour after procedure.

Do neurologists need special training to learn how to use the topical treatment? 

There are various methods for performing SPG blocks, some of which are more invasive and risk-prone than using catheter applications. The new catheter application option, which we started to utilize a couple of years ago, is easy to use and we are teaching our headache fellows and other colleagues in neurology how to use it with success.

Editor's note: This article was posted on February 6, 2019 and has since been updated.

Articles

In this podcast, Dr Heidi Moawad interviews a neurologist currently researching new, available treatments in headache medicine.

Nina Riggins, MD, PhD

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