Clinical Snippets September 2026

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Clinical Snippets September 2026 

1.  Migraine update 

(i) BPAC has published an update on migraine management including a quick access summary.   There is a reminder about the SNOOP4 mnemonic for identifying reds flags associated with headache: 

• Systemic symptoms (e.g. fever, chills, myalgia, night sweats) or condition (e.g. history of malignancy, HIV infection, immunosuppression) 

• Neurological symptoms or signs, e.g. confusion, diplopia, neurological deficit 

• Onset – sudden onset headache reaching maximum intensity within minutes (thunderclap headache) 

• Older age – onset after age 50 years 

• Progressive headache – change in headache features, pattern or severity over days or weeks 

• Precipitated by Valsalva, cough or sneeze 

• Postural or exertional aggravation, e.g. headache worsened or triggered by standing, lying down or exercise 

• Papilloedema 

(ii)  Linked resources in the article include a downloadable headache diary and the Migraine Disability Assessment Tool which helps quantify impact of migraine on quality of life and can be used to assess treatment efficacy.  There is also a link to the Migraine Treatment Optimization Questionnaire-4 (mTOQ-4) which can be used to gauge efficacy of current acute migraine therapy.  There is an easy-to-follow algorithms for acute migraine treatment, and advice on prophylaxis of migraines using both funded and unfunded medications.   

(iii) Practice points regarding prophylaxis include: 

• Consider migraine prophylaxis for patients who experience multiple episodes per month (≥ 4 migraine episodes or ≥ 8 headache days), or if acute treatments are ineffective, not tolerated/contraindicated or overused 

• Trial for two to three months at the maximum tolerated dose before assessing response 

• Review the need for ongoing use after 6 – 12 months of effective treatment 

• The choice of migraine preventative medicine largely depends on patient co-morbidities. The main funded options include beta blockers (e.g. propranolol, metoprolol), antidepressants (e.g. amitriptyline), candesartan, sodium valproate and topiramate. 

• Non-funded options for migraine prophylaxis are also available, such as calcitonin gene-related peptide targeted treatments (e.g. fremanezumab, atogepant). These medicines are effective and are generally better tolerated than conventional migraine prophylaxis medicines, but cost may limit access. 

• There is some evidence that greater occipital nerve blocks may reduce the severity and frequency of migraine episodes in the short term (weeks to months). A greater occipital nerve block is an injection of local anaesthetic (with or without a corticosteroid) into the occipital nerves at the base of the skull. The procedure is generally well tolerated; injection site pain, vertigo and nausea are common adverse effects. 

(iv)  The non-funded prophylactic treatment options are discussed in some detail.  These are injectable CGRP monoclonal antibodies – three brands available in NZ (monthly SC injections) and oral (CGRP receptor agonists ((gepants) – only Atogepant (Aquipta) available in NZ).  The strong evidence of efficacy has led to their recommendation as first-line options for migraine prevention by the European Headache Federation and the American Headache Society and they are also often better tolerated than conventional migraine preventatives.  Worsening of pre-existing hypertension and recurrence or worsening of Raynaud’s phenomenon has been reported with CGRP-targeted treatments, therefore, they should be used with caution in patients with these conditions.  While treatment is usually initiated by a neurologist, given access issues primary care clinicians can initiate these medicines if they feel confident, or seek advice from a neurologist prior to prescribing.  The Migraine Foundation website provides details on access and cost of the various preparations, which range from around $325 per month upwards.    

2.  Antidepressant withdrawal 

• The July NZ Formulary July update notes the section on antidepressant withdrawal symptoms has been updated.  The article references the RELEASE Toolkit that is endorsed by the RNZCGP but notes that practical implementation of hyperbolic tapering in New Zealand is currently limited by the availability of suitable antidepressant formulations, and the lack of standardised batch sheets for extemporaneous compounding. Specialised compounding pharmacies may be able to prepare patient-specific antidepressant suspensions at a cost to the patient; alternatively, some patients may be instructed to use tablet crushing and dispersion methods [unapproved use]. 

• These approaches require careful patient counselling and consideration of formulation limitations (e.g. modified-release preparations such as venlafaxine should not be crushed). Instructions for crushing and dispersion methods for appropriate medicine formulations can be found on the tapering plans in the RELEASE toolkit website. If hyperbolic tapering is being considered, collaborative planning, regular monitoring, patient education, and early communication with the individual’s pharmacy are essential. 

• Alternate day dosing should be avoided, as it results in fluctuating antidepressant plasma levels and can worsen withdrawal symptoms; switching from a ‘high-risk’ antidepressant to a ‘lower-risk’ antidepressant (e.g. fluoxetine) for the purposes of mitigating withdrawal symptoms has limited evidence and is not generally recommended. 

3.  Pica in iron deficiency 

An article in a recent issue of NZ Doctor reviewed pica in patients with iron deficiency anaemia.  Key points included: 

• Pica is a compulsive habit marked by ingestion of non-nutritive, non-food substances; it is common in iron deficiency (25-40% of patients).  The substances eaten might include hair (trichophagia); ash, usually from cigarettes (stachtophagia); dirt (geophagia); ice (pagophagia – most common in iron deficiency); and paper or wood products (xylophagia). 

• Many people who have monthly menstrual bleeds don’t talk with others about what is normal.  If you talk with a patient with menorrhagia, consider asking them about symptoms of pica – they might be too ashamed to bring it up, and it has a clear physiological cause they might be relieved to find out about.  Pica related to iron deficiency usually resolves with treatment of the deficiency. 

4.  Risk and benefits of iron infusions 

• BPAC Bulletin 153 notes that Ferric carboxymaltose (Ferinject/FCM) IV infusion for iron replacement treatment is associated with significant fracture risk and a higher incidence of hypophosphataemia (45-75%) than previously thought. There is a risk of fracture and osteomalacia associated with hypophosphataemia  but also through direct inhibition of bone formation by FCM, i.e. independently of hypophosphataemia, with the risk being greater in patients requiring or receiving repeated infusions. The New Zealand Formulary recommends pre-treatment testing and ongoing monitoring of serum phosphate in patients with risk factors for hypophosphataemia (e.g. low BMI, poor nutrition, chronic diarrhoea, Vit D deficiency).  Clinicians should be aware of the risks of hypophosphataemia and fracture and routinely discuss these with patients before making a joint decision to prescribe or administer this treatment.  

• The Bulletin discusses a recently published study comparing FCM with Ferric derisomaltose (FDI) infusions that reported more than doubling of the fracture risk one to six months after treatment with a single infusion of FCM compared with FDI.  The commenting haematologist noted:  The baseline five-year fracture risk of participants in the study was 5% and this increased after ferric carboxymaltose treatment to 13 – 14%; that is, 8 – 9% of people who receive an infusion with ferric carboxymaltose may have a fracture attributable to this treatment within the next five years.  At present, the only alternatives to FCM in the community are oral iron and ferric polymaltose IM injection.  FDI (Monofer) is an alternative parenteral iron formulation with comparable efficacy that is associated with a significantly lower risk of hypophosphataemia and fracture than FCM. It has been funded in the hospital setting since 1^st March, 2026 for patients who meet certain criteria (Patient had previously developed iron-infusion related hypophosphataemia or other severe adverse reaction), but is not funded for use in the community. 

5.  Access to diabetes medications 

From 1 September 2026, there has been widening of access to some diabetes medications: 

The Special Authority criteria for empagliflozin (Jardiance), empagliflozin with metformin (Jardiamet), dulaglutide (Trulicity) and liraglutide (Victoza) has been amended to make these medicines available to all people living with T2DM who are unable to reduce their blood sugar levels (HbA1c) below 53 mmol/mol using other funded diabetes medicines.  This removes ethnicity-based criteria, as well as clinical criteria related to cardiovascular risk or existing diabetic-related kidney disease. Access to dulaglutide and liraglutide require target HbA1c (of 53 mmol/mol or less) not achieved despite the regular use of all of the following blood-glucose lowering agents for a period of at least 6 months, where clinically appropriate: empagliflozin, metformin and vildagliptin, while access to empagliflozin requires failure to reach the target HbA1c despite the regular use of at least one blood-glucose lowering agent (e.g. metformin, vildagliptin, or insulin) for at least 3 months.   

6.  ACC 18 Medical Certificates 

ACC Update Improvements in the ACC18 medical Certificate form are being phased in gradually from October 2026.  The updated form will include clearer fields, improved functionality, and greater consistency with the ACC45 Injury Claim form. The changes will make it easier to: 

• record a client’s ability to work, including when they can undertake selected duties rather than being fully off work 

• identify rehabilitation and return-to-work support needs 

• provide additional recovery information where relevant 

• communicate with ACC more effectively through better structured information fields 

ACC is working directly with PMS vendors to effect the changes and will share more information about the specific form changes closer to rollout, including guidance and supporting resources.  There is also a reminder about the ACC Medical Certification dashboard that allows you to review and compare your certification and return-to-work data 

7.  Alcohol health myths 

A recent Medscape article examined current evidence for any potential health benefits of drinking alcohol and found none.  Key points from the article include:  

• Better-designed studies: any alcohol intake ↑ cancer, CV, liver disease + all-cause mortality risk. 

• No meaningful health benefit found for 1 drink/day; red wine myth not supported (the notion that the antioxidants in red wine outweigh the toxicity of the alcohol is false—you would need to consume a dangerous amount of wine to get therapeutic levels of compounds like resveratrol) 

• Older J-curve studies biased by sick quitters + healthier moderate drinkers. 

• Physician counselling improves awareness; explicit alcohol-cancer discussion ↑ patient recognition. 

• Counselling approach: nonjudgmental, harm vs health promotion, motivational, debunk myths 

8.  Paper of the month 

• A recent case report in Annals of Internal Medicine  was of a 77-year-old man with severe obstructive sleep apnoea (OSA) who developed classic exploding head syndrome (EHS), with sudden nocturnal “explosions” at sleep onset. Exploding head syndrome (EHS) is a benign parasomnia characterized by abrupt, intensely startling perceptions of loud explosions, gunshots, or crashes in the head during transitions between sleep and wakefulness. Episodes typically last seconds to minutes, are painless despite the alarming auditory phenomenon, and result in sudden arousal with autonomic activation (tachycardia, anxiety, sweating). The condition is rare and frequently underrecognized, often misattributed to psychiatric illness, migraine, or ototoxicity, leading to delayed diagnosis and unnecessary investigations. The pathophysiology of EHS remains incompletely understood but there have been case reports documenting associations between EHS and sleep-disordered breathing.  

• Current management of EHS focuses on reassurance, education about the benign nature of EHS, and sleep hygiene optimization. Pharmacologic interventions, such as calcium channel blockers (nifedipine), tricyclic antidepressants (clomipramine, amitriptyline), and topiramate, have been reported in small case series with variable efficacy. Systematic evaluation for coexisting OSA) and the potential benefit of CPAP are not yet standard in routine care, despite emerging evidence that sleep-disordered breathing may contribute to symptom generation. 

• In the case in question, the patient initially used a mandibular advancement device, which only partially controlled respiratory events. After starting CPAP with excellent adherence and with a residual Apnea-Hypopnea Index score below 5 events per hour, EHS episodes decreased from frequent, debilitating events to about once monthly, alongside improved sleep continuity and daytime alertness. This case suggests that OSA may be a modifiable contributor to EHS and supports routine evaluation for sleep-disordered breathing in patients with this underrecognized parasomnia.