Headache NewsBlog

Not all narcotics are equally addictive

By: Dr. Mauskop

08-05-2013

Abuse of prescription narcotic (opioid) drugs is growing at an alarming rate and they are responsible for tens of thousands of deaths due to overdose every year. While all such drugs can cause addiction, there appears to be a difference among these drugs. A study recently published in The Journal of Pain suggests that a new opioid pain killer, tapentadol (Nucynta) is less likely to cause addiction than oxycodone (Percocet, Percodan, Endocet). The study was conducted by the manufacturer of Nucynta, a subsidiary of Johnson & Johnson. The researchers looked at the risk of shopping behavior (going to more than one doctor to obtain prescriptions) in over 150,000 patients. People who were prescribed oxycodone were four times more likely to be doctor shoppers than those who were prescribed tapentadol. Also, 28% of those prescribed oxycodone were asking only for oxycodone, while only 0.6% of those prescribed tapentadole were asking for tapentadol. This means that of those prescribed tapentadol less than one percent were asking only for tapentadole and the rest asked for other narcotics. Tapentadol has another advantage in that it causes less nausea and constipation than other opioid drugs.

Abuse potential is also reduced by making the pill temper resistant. About two years ago Oxycontin, which is one of the most popular (and most abused) long-acting narcotic pain killers was reformulated to make it difficult to crush. Because Oxycontin is a long-acting drug and does not give a quick high, addicts usually crush the tablet and inject or snort it. The new formulation prevents it from being crushed and in the past two years the abuse (and the sales) of Oxycontin has dropped. The FDA recently denied permission to sell generic versions of Oxycontin because they did not have such temper-resistant properties.

Unlike with other types of pain, opioid drugs seem to be less effective in the treatment of migraine and other headaches. Headache patients often report little relief from these drugs, as well as side effects, such as nausea and sedation. Opioid analgesics, such as codeine, hydrocodone (Vicodin), oxycodone (Percocet), and other can actually make headache worse in some patients by causing rebound, or medication overuse headaches. However, there are exceptions to this rule and a very small number of our patients respond only to opioid drugs and a few are doing well with daily long-acting narcotics. To make sure these drugs are not being abused we carefully select and closely monitor such patients.

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Fear delays recovery in whiplash injuries

By: Dr. Mauskop

04-05-2013

Pain

Fear and avoidance of activity may play a role in fostering disability in whiplash-associated disorders, according to a new study by University of Washington researchers published in the latest issue of journal Pain. This study examined the role of fear after whiplash and assessed the effectiveness of 3 treatments targeting fear. They evaluated 191 people still suffering from whiplash symptoms 3 months after the injury. Patients were assigned to one of the following three treatments: (1) informational booklet describing whiplash disorder and the importance of resuming activities, (2) informational booklet plus a discussions with clinicians reinforcing the booklet, and (3) informational booklet, plus a psychological technique called imaginal and direct exposure desensitization to feared activities. The second and the third group received three 2-hour treatment sessions. Those given psychological intervention reported significantly less post-treatment pain severity compared with those given a brochure or brochure and discussion. Reduction in fear was the most important predictor of improvement, followed by reductions in pain and depression. The authors concluded that the results highlight the importance of fear in individuals with persistent whiplash injury symptoms and suggest the importance of addressing fear through exposure therapy and educational interventions to improve function.

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Prophylactic migraine drugs are all equally mediocre

By: Dr. Mauskop

01-05-2013

Headache medications

Preventive drugs for migraine headaches help less than half of the patients they are given to. There is no significant difference in effectiveness in these drugs. They reduce frequency of attacks by 50 percent, according to a review published in the recent issue of the Journal of General Internal Medicine.

Dr. Shamliyan from the University of Minnesota in Minneapolis and her colleagues conducted a literature review to identify high quality clinical trials of preventive drugs versus placebo.

Based on 215 published trials, the researchers found that all FDA-approved drugs, including topiramate (Topamax), divalproex (Depakote), timolol (Blocadren), propranolol (Inderal) and off-label medicines metoprolol (Toprol), atenolol (Tenormin), nadolol (Corgard), captopril (Capoten) and lisinopril (Zestril); and candesartan (Atacand) were effective in reducing monthly migraine frequency by 50 percent or more in 20% to 40% of patients. Topiramate, other off-label antiepileptics, and antidepressants had higher levels of side effects and were more likely to be stopped by patients because of side effects. While there were no significant differences in benefits between approved drugs, candesartan and other blood pressure drugs were the most effective and had fewest side effects for the prevention of episodic migraines.

The authors also noted that there was no evidence for long-term effects of drug treatments (that is trials lasting more than three months).

This review confirms my bias in favor of Botox injections over drugs. Botox helps not only 70% of chronic migraine patients, but in my anecdotal (but involving thousands of patients) experience it is equally effective for the prevention of frequent episodic migraines.

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Anxiety and depression are associated with various pains and migraines

By: Dr. Mauskop

28-04-2013

Science of Migraine

It is a well established fact that migraine sufferers are 2-3 times more likely to develop anxiety and depression. The reverse is also true: if you suffer from anxiety and depression, you are 2-3 times more likely to develop migraine headaches. These associations are called comorbidities. Anxiety and depression are also comorbid with other pain syndromes. A group of Dutch researchers examined records of almost 3,000 patients with anxiety and depression to look for the presence of comorbid migraines and pain in the back, neck, face, abdomen, joints, and chest. All patients were interviewed twice, with a two year interval, and were asked if they had any of those pains in the preceding 6 months. Their results, published in The Journal of Pain, clearly show that having anxiety and depression increases the risk of developing migraines and other pain syndromes equally. So, this association is not specific to migraines, but applies to all pain syndromes. This means that anxiety and depression do not cause headaches and pain and the other way around. Most likely, one condition predisposes the sufferer to develop the other. It is also likely that shared genetic predisposition or the involvement of certain brain chemicals that are involved in both pain and depression, such as serotonin, adrenalin, and other, may be responsible for these associations.

Botox relieves myofascial (muscle) pain

By: Dr. Mauskop

24-04-2013

Pain

Botox seems to help neck and upper back muscle pains, according to a recent study by UCLA doctors. We know that one of the actions of Botox is to relax muscles and it has been effective for the treatment of sciatic pain, according to a previous blinded study. Drs. Nicol and Ferrante at UCLA gave a single injection of Botox to 118 patients with neck and upper back pain. Six weeks later 54% of patients showed improvement. Then, 8 weeks later, half of the 54 responders were given again Botox and the other half placebo (saline injection). Those who received Botox did much better not only on pain scores, but also on quality of life measures. They also had a significant improvement in the number of headaches. This is not that surprising, since many of our patients report that their headaches begin with muscle spasm in the neck or upper back. It is very likely that giving more than one injection will lead to a greater improvement in a larger percentage of patients. In chronic migraine headache patients injecting Botox into 31 sites has been proven to be very effective.

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A new procedure for pseudotumor cerebri

By: Dr. Mauskop

22-04-2013

New treatments

A new treatment for pseudotumour cerebri was reported by a team of interventional neuroradiologists and neurosurgeons. Pseudotumour cerebri is a rare condition, which manifests itself by increased pressure in the head, leading to severe headaches, vision impairment and even complete loss of vision and brain damage. It affects more women than men and usually occurs without an obvious trigger, although pregnancy, obesity, and certain medications increase the risk of developing this condition. The diagnosis is made by performing a spinal tap (lumbar puncture) and measuring cerebrospinal fluid pressure. Typical MRI scan findings (narrowing of the ventricles – cerebrospinal fluid filled spaces in the brain) and finding of swollen optic nerves (papilledema)on eye exam confirm this diagnosis.

The new treatment is based on the theory that narrowing of a vein located at the back of the brain is the underlying cause, although this theory remains controversial. Narrowing of this vein is thought to reduce drainage of the cerebrospinal fluid from inside the brain, leading to build up of this fluid and increased pressure inside the skull. The usual treatments for pseudotumor include weight loss, medications that reduce pressure, such as acetazolamide (Diamox), and the surgical placement of a shunt to continuously drain spinal fluid from the brain, thus reducing the pressure.

The study, published in the online edition of the Journal of Neuro-Ophthalmology, shows that lowering pressure inside the vein alleviates the condition and improves vision. The doctors at Johns Hopkins used an advanced ultrasound scanner to thread an expandable metal stent through a vein in the groin, all the way to the transverse sinus, one of the main veins inside the skull draining fluid from the brain.

The study involved only 12 patients, but all of them had immediate relief of their headaches and 10 had lasting improvement. The researchers admitted that the efficacy of this treatment needs to be confirmed in a larger group of patients.

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Levadex is delayed again

By: Dr. Mauskop

19-04-2013

New treatments

Approval of the inhaled dihydroergotamine or DHE to be sold under the name of Levadex has been delayed again by the FDA. We expected approval last year because the FDA did consider the product to be safe and effective, but they were not happy with the manufacturing process. The application for approval was resubmitted and we all expected the product to become available in the middle of this year, but apparently the FDA still has the some concerns about the manufacturing. If all goes well Levadex may come to the market at the end of 2013. In the past few months the small company that developed Levadex, MAP Pharmacueticals sold itself to the maker of Botox, Allergan. Allergan hopes to find synergy between Botox, which is approved for the prevention of chronic migraines and Levadex, which is indicated for the treatment of an acute migraine attack. It will be much more efficient for Allergan’s sales force to sell two complementary drugs to neurologists rather than just one. Both are excellent drugs with high efficacy (70% for Botox and 60% – 70% for Levadex), excellent safety for Botox and relatively good safety for Levadex (comparable to triptans, such as Imitrex).

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Elimination diet based on antibodies in the blood helps migraines

By: Dr. Mauskop

17-04-2013

Alternative Therapies

Food sensitivities have been always suspected to be a trigger for migraine headaches. A group of Turkish neurologists published a study in the journal Headache in which they gave an elimination diet to 21 migraine sufferers who also had irritable bowel syndrome (IBS). The study was double-blind, randomized, controlled, and cross-over, which is the most reliable type of study. Depending on the results of blood tests against 270 potential food triggers each patient was given a diet that eliminated foods they tested positive for. On average, patients were sensitive to 23 items. Compared with baseline levels, elimination diet was associated with significant reductions in migraine attack count, maximum attack duration, maximum attack severity, and number of attacks requiring medication. There was a significant reduction in pain-bloating severity, pain-bloating within the last 10 days, and was a significant improvement in quality of life by the elimination diet as compared with provocation diet.
The authors concluded that food elimination based on IgG antibodies in migraine patients who suffer from concomitant IBS may effectively reduce symptoms of both disorders with a positive impact on the quality of life of patients.
A similar, but much larger double-blind study published in 2011 compared true and sham diets in 167 migraine sufferers. 84 patients received a diet that eliminated trigger foods identified by IgG testing and the other 83 a sham diet and neither the doctor nor the patients knew who received a true elimination diet and who was given a sham diet. After 12 weeks on these diets there was no difference between the true and the sham group, suggesting that IgG testing is not useful.

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Pleasant pain???

By: Dr. Mauskop

12-04-2013

Pain

The importance of context: When relative relief renders pain pleasant, is the title of an article recently published in the leading international medical journal, Pain. British and Norwegian researchers examined how context can influence the experience of any event. For instance, the thought that “it could be worse” can improve feelings towards a present misfortune. They measured hedonic (pleasant) feelings, brain activation patterns, and skin conductance (which indicates stress, since increased sweating increases electrical skin conductance; this phenomenon is also used in biofeedback). 16 healthy volunteers experienced moderate pain in two different contexts. In the “relative relief context,” moderate pain represented the best outcome, since the alternative outcome was intense pain. However, in the control context, moderate pain represented the worst outcome and elicited negative hedonic feelings. The context manipulation resulted in a “hedonic flip,” such that moderate pain elicited positive hedonics in the relative relief context. Somewhat surprisingly, moderate pain was even rated as pleasant in this context, despite being reported as painful in the control context. This “hedonic flip” was confirmed by skin conductance and brain activation patterns on MRI scans. When moderate pain was perceived as pleasant, skin conductance and activity in certain parts of the brain were significantly reduced, relative to the control moderate stimulus. “Pleasant pain” also increased activity in reward and pain relieving brain centers. The context manipulation also significantly increased connections between reward circuitry and the pain relieving centers.

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More about catastrophizing

By: Dr. Mauskop

08-04-2013

Pain Research

It is not surprising that persistent pain can cause depression, but a study just published in The Journal of Pain suggests a possible mechanism and more importantly a possible treatment. Australian doctors examined 669 patients who were over 60 years old and were seen at a pain clinic. Catastrophizing, measured by a validated scale, was a reliable predictor of depression. They showed a strong correlation between pain intensity, catastrophizing, and depression. That is, if someone tended to think thoughts such as, “I will never get better” or “I cannot go on like this” they were also more likely to be depressed. Fortunately, this kind of thinking can be changed with psychological interventions and such change usually leads to improvement in pain.

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Melatonin prevents migraine headaches

By: Dr. Mauskop

02-04-2013

New treatments

Melatonin does seem to help prevent migraine headaches according to a new study by Brazilian researchers just presented at the annual scientific meeting of the American Academy of Neurology. In my previous post over two years ago I wrote about a negative study that showed no benefit from 2 mg of extended release melatonin given to 46 migraine sufferers. This new study was also blinded and it compared 3 mg of immediate release melatonin with placebo and with 25 mg of amitriptyline, which is one of the oldest preventive drugs for migraines.
This was a larger study – it involved 196 patients who suffered from 2-8 attacks of migraine with or without aura each month. The number of headache days dropped by 2.7 days in the melatonin group, 2.18 for amitriptyline, and 1.18 for placebo. Melatonin significantly reduced headache frequency compared to placebo, but not to amitriptyline. Not surprisingly, melatonin was better tolerated then amitriptyline. Considering its safety and very low cost, it is worth considering a trial of 3 mg of melatonin for the prevention of migraine headaches. Some studies have suggested that taking a much smaller dose of 0.3 mg (300 mcg) of melatonin may be more effective for insomnia than taking a much larger dose. It would be interesting to see if this also applies to the treatment of migraine headaches.

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Vagus nerve stimulator seems to work for acute migraines

By: Dr. Mauskop

31-03-2013

New treatments

Vagus nerve stimulation (VNS) seems to be effective for the treatment of migraine headaches. In my post over a year ago I mentioned our study of a device that stimulates vagus nerve with an external portable device. The results of this study were just presented at the annual scientific meeting of the American Academy of Neurology. The device was developed by scientists at ElectroCore, a small company following my publication of a study of implantable VNS in 6 patients. In the current study we included patients with migraine with or without aura. Participants acutely treated up to 4 migraine attacks with this portable VNS within 6 weeks. Treatment consisted of two, 90-second doses, at 15-minute intervals. Patients were asked to self-treat once pain became moderate or severe, or after 20 minutes of mild pain. Of 30 enrolled patients, 26 treated 79 migraine headaches. At two hours, 46 of 79 headaches (58%) responded, and in 22 out of 79 (28%) pain was completely gone. At two hours, 76 of 79 (96%) were improved or did not worsen. Of 26 patients 20 (77%) reported mild or nor pain at 2 hours, for at least one treated headache. Side effects were limited to muscle or skin irritation and two reports of lightheadedness, most of which resolved immediately after treatment, and all within two hours of treatment. These are very preliminary results, but they suggest that VNS may be an effective and well-tolerated acute treatment for migraine. Additional large clinical trials are needed to confirm these findings.

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