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Acetaminophen / Paracetamol – Not safe during Pregnancy after all?

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This wasn’t really the news we wanted to hear.  After all that women with headache have to deal with during pregnancy – now there’s doubt about just how safe Tylenol is.

Pregnancy and Tylenol

A study published in JAMA Pediatrics in February studied the link between acetaminophen / paracetamol and behaviour problems linked to attention-deficit/hyperactivity disorder (ADHD).

The study used telephone interviews during pregnancy and 6 months after, and then the follow-up 7 years later.

The researchers found that use of acetaminophen / paracetamol did increase the risk of ADHD.  They also discovered that if the mother used the drug during more than one trimester, the risk increased.  If more Tylenol was taken, the risk also increased.

On one level this is very discouraging news with anyone with chronic headache, who may be taking acetaminophen /paracetamol more than a few times over nine months.  It also demonstrates that there may be “subtle” issues that are not studied yet – side effects for the baby that we don’t even yet understand – that this and other drugs may be causing.

Every medication comes with risk.  We need to do our best to weigh the risk and benefit.  Although many of the risks are simply unknown, in the modern age of powerful computers we can expect to see more risks like these come to light as studies become more sophisticated.

On another level, however, this may not be as big an issue for many mothers.  For those with migraine, Tylenol is likely not the best choice anyway, and may be very little help.  More complete targeted treatment, including non-drug treatments, can be a great help to pregnant women.

Of course that doesn’t mean we’re getting away from risk – just this risk.  But it does mean that there may be treatments that are effective enough that the woman can take fewer drugs, and have less pain during pregnancy.

Dr. Alexander Mauskop has some thoughts on this study and treatment during pregnancy here.  Read the abstract on the study at Acetaminophen Use During Pregnancy, Behavioral Problems, and Hyperkinetic Disorders.  See also Can Pregnant Migraineurs Take Drugs?

“Proof” that Headaches are caused by Stress?

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Whether or not stress causes headaches, a recent study out of Germany is causing a LOT of buzz in the media.  The study, which links stress and headaches, is being hailed by some as “obvious”, and others as the final “proof” that headaches are caused by stress.

Does stress really cause headache?

But can we really now chalk up our headaches to stress?  Or is there something else going on here?

The study released this week involved a survey of 5,159 people over a two year period.  Each person had to rate their stress level (from 0 to 100) and note how many headaches they had had each month.

The headache types were classified – migraine and tension-type headache (or a combination) being the main culprits.

The study showed that increased stress levels were related to an increased number of attacks (in this case, “headache days” per month).  For example, those with tension-type headache had 6.3% more headaches when their stress rose by 10%.  Those with migraine had 4.3% more when their stress rose by 10%.

Now Jenny Hope, writing for the Mail Online (which has had a lot of good information on headache conditions in the past) came up with the unfortunate headline “It’s official – stress DOES cause headaches“.

Really?

The headline was softened with the subtitle – (and the pain then causes us to become even more stressed)

We should have some serious concerns about headlines like this, but first let’s give the researchers some credit.

What does the study say about headaches and stress?

Study author Dr. Sara H. Schramm isn’t nearly so definite in her comments.  Quoted in Medscape, Dr. Schramm says (emphasis mine):

The results add weight to the concept that stress can be a factor contributing to the onset of headache disorders, that it accelerates the progression to chronic headache, exacerbates headache episodes, and that the headache experience itself can serve as a stressor…

Did you notice?  She’s basically saying that stress is one possible factor, and that the headaches may be causing at least some of the stress!

Filling in a survey on stress and headaches is not going to clearly show what causes what.  Does stress lead to headache?  Or headache to stress?

Now this study was designed to study the relationship between stress and headache.  So it did filter out some factors, such as smoking.  In other words, if you’re stressed and smoke more, that may trigger more headache attacks, but that should have been filtered out of the study.

So this study most certainly adds to the evidence that headache disorders and stress levels are related.

But – a cause?

But saying that this study proves that headaches are caused by stress is highly problematic.  Even if stress adds to symptoms, that’s not to say that the root cause is stress.  And again, how much do the headache symptoms cause the stress?  (If you have headache or migraine issues, you’ll probably say – a LOT!)  What kind of stress?  Why are some people under a lot of stress, and yet they don’t get headaches?

Why all the bother?  So what if stress leads to headache?

So who cares?  Does it really matter if we attribute our headache disorders to stress?

Yes – it matters a great deal.  Even the author of the study admits – this is only one possible factor.

And yet articles online, and doctors around the world, not to mention friends and family of the headache patient – are very quick to say,“It’s just stress”.

But if we look closer at the research over the past few years, we should have a lot less confidence that it is.

Attributing headache disorders primarily to stress is keeping patients from treatments that could be helping them.  It’s keeping them from discovering triggers that may be even more powerful than stress.  And it’s often making patients feel guilty for something that isn’t their fault.

Why is it that there are two people under stress, and one gets severe headaches and the other none?  Why not look for other factors and treatments, rather than writing off the symptoms and saying they’re just due to stress?

What we should learn from the study

Although we shouldn’t be jumping to conclusions based on a survey like this, there are valuable things that can be learned from the study.  Dr. Schramm puts it this way:

These results show that this is a problem for everyone who suffers from headaches and emphasize the importance of stress management approaches for people with migraine and those who treat them…

Is stress a major issue for those with frequent headache symptoms?  There is no doubt that this is commonly the case.  So should we be helping patients manage stress?  Of course!  This should be a part of overall treatment.  And this study shows us once again that there is a clear relationship between tension-type headache or migraine and stress.

This study also points to the need for more studies on stress and headache disorders.  Dr. Todd A. Smitherman, a psychologist from the University of Mississippi who was not involved in this study, gives his suggestion for what’s needed:

Problematically, the overwhelming majority of studies on stress as a headache trigger have relied on either retrospective or prospective patient reports of stress.  What is needed are experimental studies that directly manipulate stress, measure resulting physiological changes, and try to link these changes to subsequent headache activity.

He goes on to point out that the stress-migraine relationship has not always been clear.  We need better measurements of types of stress, changes in stress, and types of headache.  (Read more in More Stress Equals More Headaches from Medscape)

So let’s not take a step back into the world of “It’s just stress”.  Modern science has shown again and again that headache disorders are much more complex, and that the treatment must include but go far beyond “relax and breath deeply”.

Read more on the study from the American Academy of Neurology:  Does More Stress Equal More Headaches?

Patent foramen ovale closure – for children?

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Patent foramen ovale closure is still being used as a treatment for migraine and other headaches in children.  But is it worth the risk?

Patent foramen ovale (PFO) closure is the closing of a common “hole in the heart” that once was hoped to be a great new migraine treatment.  So far, however, the surgery has not lived up to the original hype.  Trials have failed to put this anywhere close to the top of the list when it comes to migraine treatment.

In spite of the general let-down, the treatment is still being used, even among children.

It has been estimated that one in four people have PFO, but most people have no symptoms at all.  But in some people this does seem to contribute to migraine.

Pediatric Neurology recently published a study from the USA on PFO treatment for children in general.  Children with both migraine and non-migraine headache usually reported an improvement after the surgery.

So far so good.  However, the researchers have some concerns, and rightly so.

First, this study was not designed to see how effective PFO closure was in patients, and so it had a number of shortcomings which we won’t get into here.  But there are some things that would be helpful to know.  For example, did these patients have other symptoms besides headache or migraine that prompted them to see a cardiologist (in most cases, the procedure was recommended by a cardiologist)?  If so, could it be that treating other conditions are actually helping with migraine symptoms?

Researchers are also concerned about long term effects of this surgery (it’s a generally safe surgery, but it’s still surgery), and the cost.  If there are less-invasive treatments that work just as well or better, doctors should be cautious about recommending PFO closure.

This study highlights the need for further well-designed studies of PFO closure for migraine and headache.  For example, I would like to see further study into type of migraine or headache vs type of PFO.

We’re still getting mixed answers about how helpful it is, and we need to be especially cautious before we recommend it for children.

For more information:

Stop Paying for Migraine Drugs – and Take Placebos?

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A study published this month is sparking debate about whether or not we should even bother paying for common migraine medications.  Does a “fake pill” work just as well as the real thing?

Headlines such as “Migraine sufferers benefit from placebos, study shows” may be sending the wrong message.  So – migraine is all in their heads after all?  People can just “think” their headaches away?

But if you know anything at all about the science of medicine, your reaction is more likely to be – this is news?  Really?!

Placebos usually refer to treatments that are thought to be “real” but aren’t.  In this case, there’s the common migraine medication rizatriptan and a pill that contains no medicine at all.

It’s no surprise at all that placebos help with a variety of very real conditions – including many pain issues, and even conditions such as congestive heart failure.  Well designed studies control for the placebo effect.  It’s nothing new at all.

There are positive and negative effects.  The nocebo effect happens when a treatment seems to harm someone when they think that it will.

In this particular study, it was found that rizatriptan did work better than a placebo.  However, if a patient thought that a placebo was rizatriptan, they did just as well as the patient who thought the rizatriptan was a placebo.  Positive and negative impact worked together to level the playing field.

This study certainly shows us again how powerful the placebo effect can be.  It does not, however, negate hundreds of studies showing that migraine treatments are usually more beneficial than a placebo.

It should also be noted that the study covered just 6 migraine attacks per person, and so does not say a lot about long term treatment.

What we do want to do is harness the power of the placebo effect.  In spite of the fact that most people want their doctors to tell the truth, the truth is that many, many doctors actually do prescribe placebos as if they are “real” medical treatments, knowing that the ruse will often help the patient.

On the more ethical side, most doctors do speak positively about a drug that should help you.  “Expecting the best” will increase your odds, no doubt.

So although there is no scientific reason to doubt the power of real migraine medications that have been carefully researched, there is also good reason to continue investigating placebos for all kinds of medical conditions.  We may not be able to think our way to a migraine cure, but being positive can make a huge difference.

Study abstract:  Altered Placebo and Drug Labeling Changes the Outcome of Episodic Migraine Attacks

Why Spitting it out could Stop Headache Pain

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Another study is encouraging headache sufferers to spit it out.  Chewing gum, that is.

The study published this month in Pediatric Neurology followed thirty children and adolescents who chewed gum and head headaches.  Some chewed for less than an hour a day.  Others were serious gum-chewers – we’re talking Violet Beauregarde – who chewed more than 6 hours a day.

Some were diagnosed with migraine, others with tension-type headache.

Once they stopped chewing, the results were amazing:

When they stopped chewing...

Now, you’re wondering if the occasional chewers improved, or just the obsessive chewers.  The good news is that they all improved.  It didn’t make much different if they chewed a little, or a lot.

Why the difference?  Researchers aren’t sure.  It could be the artificial sweeteners such as aspartame, which are almost omnipresent in chewing gum these days.  It could be the stress on the joints of the jaw.  It could also be the strain on the jaw’s muscles.

But whatever the reason, it could be that many children and teens could see significant improvement by doing one simple thing – spitting out the gum.

It should be noted that many of the possible triggers from chewing gum could also be triggered by clenching and grinding teeth, whether during the day or while you sleep.  Relaxing the jaw could mean serious improvement for many headache patients.

For more information, see the study here:  The Influence of Excessive Chewing Gum Use on Headache Frequency and Severity Among Adolescents

via Chewing gum may cause headaches.

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