opioid

17 December 2020

Pupils Constricted During a Headache Attack?

Have you ever noticed a change in the size of your pupils during a migraine attack?

To be fair, this is probably the last thing you’re thinking about. But maybe someone else has noticed. Dilated pupils – that is, larger pupils, caught the attention of this writer as a significant migraine symptom – Eye Pupils Dilated during Migraines- Is that Normal? The condition in which pupils dilate unusually is called mydriasis.

But according to most research, and a recent study, the opposite is more likely to be true – constricted pupils (this condition would be called miosis). This has been observed in conditions such as hemicrania continua and cluster headache.

A recent study published in the European Journal of Ophthalmology investigated constricted pupils in migraine. The study of 24 patients and their 48 eyes showed that migraine patients did tend to have significantly constricted pupils during attacks. There was no significant difference between the two eyes – in other words, patients with a headache on one side of the head had similar constriction in both eyes, not just on the painful side.

Apart from being an interesting symptom to keep an eye on (oops! sorry!), it will also open up future study into how muscles and nerves around the eye respond to migraine attacks – or how they are involved in the web of causes and effects.

If your pupils are constricted during migraine, you can probably simply think of it as another strange migraine symptom. However, certain medications – namely opioids and other narcotics, may also cause constriction. If you’re regularly taking one of these medications during a migraine attack, you might want to talk to your doctor about other long term solutions to avoid and treat migraine pain.

Read the study abstract here: Effect of migraine attack on pupil size, accommodation and ocular aberrations

9 December 2019

Discovery: A Link Between Opioid Overuse Pain and Migraine Pain

James Discoveries & Stats 0

Researchers at the University of Illinois have discovered a fascinating link between opioid overuse and migraine pain. This particular link is a good sign for new medications that are being studied now. Could these new medications help some migraine patients fight migraine and past opioid overuse at the same time?

PACAP levels - a key to ending your head pain? — PACAP and head pain

Senior author Amynah Pradhan explains what the team was trying to find out:

“Endorphin is an example of a peptide that signals the brain to give a ‘runner’s high.’ However, not all peptides signal for pleasant outcomes. Pituitary adenylate cyclase-activating peptide, or PACAP, is a peptide that can induce migraines in migraine-prone individuals. Because the overuse of opioids can lead to worse migraines, we wanted to determine whether opioid-induced pain changed the amounts of peptides in the brain and understand if pain from migraines and opioid overuse shared any peptides in common.
Amynah Pradhan [source]

As you might guess, the link was found. In this study with mice, PACAP was high in models with migraine pain and models with opioid pain. This could help to explain why opioid use leads to “rebound headache” for migraine patients.

Of course this helps us further understand migraine and how it interacts with opioid use, which can be helpful in some cases but often ends up being harmful. But even more interesting is that medication for migraine is being developed right now which targets PACAP levels. We’ve talked before about two medications being developed, ALD1910, and AMG 301, which target these peptides. This from Alder Biopharmaceuticals:

Alder is developing ALD1910, a preclinical monoclonal antibody (mAb) designed to inhibit pituitary adenylate cyclase-activating polypeptide (PACAP) for migraine prevention. PACAP has emerged as an important signaling molecule in the pathophysiology of migraine and represents an attractive novel target for treating migraine. ALD1910 may hold potential as a migraine prevention treatment for those who have an inadequate response to other therapies and could provide another mechanism-specific therapeutic option for migraine patients and their physicians.
[source]

Could it be that these new medications would especially help patients who have been regular opioid users in the past?

For more, see this from ScienceDaily: A new link between migraines, opioid overuse may be key to treating pain

7 July 2016

Medication Overuse Headache: Overrated?

James Medications, News 6

Everybody is talking about medication overuse headache (MOH). There is a big push to cut down on drugs and to find alternatives. But is it possible that we’re over-emphasizing the problem?

At last month’s meeting of the American Headache Society in San Diego, organizers set up a discussion on the topic – is MOH actually a thing?

Ok, the thesis was “Medication Overuse Headache is a Proven Entity” – true, or false?

Taking opposite sides were Dr. Richard Lipton (“true”) and Dr. Ann Scher (“false”) (two experts who have actually worked together on a number of projects in the past).

The discussion is, of course, a lot more nuanced than that. Just what is MOH? What medications can cause MOH? How much of a certain drug is too much? Are there permanent consequences to MOH? Or is it easily resolved?

Medication Overuse Headache: How big is the problem? Dr. Scher brought up an important point. Common current advice is to limit abortive medication to 2x per week or less. Medications that should especially be avoided include opioids and butalbital combination medications. So the question is – How many are being harmed vs helped by this advice?

That is the bottom line, right? Whatever the details may be, is the current focus, the current common advice, actually helping patients?

For example, is it better to take a little too much (no, we’re not talking about multiple doses per day here), or to completely quit the medication?

Few would disagree that MOH exists in some form, but there is not equal evidence for every medication.

Dr. Alexander Mauskop, who kindly reported on this discussion for us (see The existence of medication overuse headache is debated), actually advocates the use of daily triptans for a few patients. Other doctors would be horrified by the thought.

The heart of the discussion really isn’t whether or not medication overuse headache actually exists. The question is – where is it really a problem, and how can it be treated? And the truth is, we have a long way to go before we’ll have good answers to these questions. It’s good to see the discussion moving forward.

30 July 2013

Pain: Should Women be treated differently than Men?

James Discoveries & Stats, Medications 3

Dr. Paul Spector, certified Health Fitness Specialist and director of Pantheon Medicine, wrote a fascinating article which appeared in the Huffington Post earlier this month (Women in Pain). In the article, he challenges the way that women with chronic pain are treated in the health field.

It’s the same old debate, in a way. We all want to see men and women treated “the same”, in the sense that they both get quality health care. On the other hand, getting “the same” treatment must mean that men and women are treated differently, simply because they’re physically different.

Some of those differences are, of course, partly cultural. For example, men may be more reluctant to show weakness. Which means women are more open and more likely to tell their doctors about pain. Which could mean that women are perceived as “over-reacting” or “emotional”, when in reality they may just be coping better. Which means they may not be taken seriously.

Dr. Spector suggests four ways in which women are different:

Women are more sensitive to pain than men
Women have a higher prevalence of painful conditions than men
Women seek medical help more often than men
Women have received less pain medication than men and have had their condition discounted as psychogenic or emotional and therefore not worthy of treatment

Dr. Spector is actually responding to a discussion from the Centers for Disease Control and Prevention, the CDC Telebriefing on Deaths from Prescription Painkiller Overdoses Rise Sharply Among Women. In the discussion, Dr. Thomas R. Frieden (director of the CDC) suggests that, although men are more likely to die from an opioid overdose, the gap is narrowing.

What seems to be happening is that women are being prescribed more and more opioids (think methadone, codeine, hydrocodone, oxycodone, and meperidine).

Most of these deaths are not intentional – we’re not talking about an increase in suicides. Sometimes it would be an intentional overdose, or a mix of drugs or drugs and alcohol, etc, that would end in a death. There could also be situations when someone is sharing drugs with someone else.

From the standpoint of headache disorders, in the widespread problem of migraine disease women are more likely to have migraine. Both men and women can be stigmatized, there’s no doubt. But from a strictly anecdotal standpoint, it certainly seems like many women are written off and ignored in a way that I never have been.

Because of the prevalence of migraine in women, it does tend to be studied more than migraine in men. And that’s only natural.

But maybe there are problems with treatment for both genders – for different reasons and in different ways.

Do you feel that you’ve received poorer treatment because of your gender? How do you think doctors could do better? If you’re a doctor, what have you seen? What have you done to ensure that a woman or man with a headache disorder gets the treatment they need?

9 January 2012

New Clues about Medication Overuse Headache and Opioids

James Medications 7

In the video below, researcher Dr. Julie Wieseler discusses new research into the opioid medications.

Opioids include medications such as codeine and meperidine (Demerol). They’re common when it comes to migraine treatment, but they’re also highly suspect when it comes to Medication Overuse Headache (MOH). Meaning – taking them for migraine symptoms can temporarily help, but make symptoms worse later on. (Actually, most medications can do this – but opioids seem to be among the more likely)

Researchers have noticed that taking opioid medications can make symptoms of cutaneous allodynia worse – but why?

The investigation began to see why exactly this migraine treatment was causing more symptoms in the long run. Their results, discussed in the video below, may help researchers find better treatments, or use opioids more safely, or find ways to prioritize treatments that are less likely to cause MOH.

Find out more about this new research here: Why Opioids Enhance Migraine Pain: The Puzzle Points to Glia