Medications

10 September 2015

Drugs For Headache: Infertility?

A report at the European League Against Rheumatism Congress 2015 is raising concerns about the use of certain anti-inflammatory drugs (NSAIDs). The study clearly showed the link between the medications and infertility.

cradle In this case, the connection was quite clear. While taking the medication (participants took it over a period of 10 days), the patients were much likely to ovulate – much less likely.

The drugs in the study were diclofenac, etoricoxib and naproxen. Of the control subjects (those taking none of the above), 100% ovulated. Of those taking etoricoxib, only 27.3%. Of those taking naproxen, 25%, and of those taking diclofenac, only 6.3%.

The good news is that the effect seems to be temporary – that is, only when the women were actually taking the medication (yes, they checked back a month later). But this and other previous studies do raise a number of questions. What about a lower dosage? What about one dose every couple of days? Is there a cumulative effect for someone frequently taking a NSAID? What about other NSAIDs, like ibuprofen?

This study is yet another reminder that we need to get away from “take two and call me in the morning” – no discussion of the alternatives or the risks. And headache/migraine treatment needs to be a lot more than masking pain.

For more information, see:

7 September 2015

Severe Headache in Pregnancy – What’s the Answer?

James Discoveries & Stats, Medications 1

There are quite a few excellent treatments for headache in pregnancy. The situation does get a little more difficult, however, when an unexplained headache lands you in emergency, and you want to take something that will help break the pain cycle.

Emergency Headache Treatment in Pregnancy Acetaminophen / paracetamol is a common drug to try first. In the case of migraine, intravenous magnesium may be tried as well.

But after that, the possibilities are a little more controversial. There are narcotic treatments, for example, which are being used less and less because they seem to be less helpful overall and may cause problems in pregnancy. NSAIDs and triptans are sometimes avoided in pregnancy, although it’s a matter of risk, and triptans are being more often accepted today. In that case, a medication such as sumatriptan may be given by injection.

Dr. Katherine Scolari-Childress wanted to know if there was a better option, so she tested a combination treatment against an older standard, codeine.

The women were first treated with 650-1000 mg of paracetamol/acetaminophen, but this treatment did not do enough to relieve the pain.

The combination that was being tested is intravenous metoclopramide (often given for nausea) and diphenhydramine (an antihistamine). Out of 46 pregnant women with normal blood pressure, 100% responded to just one dose (only about 2/3 responded to the codeine). 65% had full headache relief. Women taking the combination also spent slightly less time in the unit.

Almost every woman said she would use the medication combination again.

Doctors in emergency need to take notice of new treatments that may work better for pregnant women. As less effective drugs are phased out, and others are in some cases too high a risk, there are still excellent treatments which can provide relief in a way that is safe for mother and baby.

For more information: IV regimen safely resolved acute headache in pregnant women

1 September 2015

Generic vs. Name Brand: What’s the Difference? (videos)

James Medications 0

Yes, there is a difference. But that doesn’t mean that you shouldn’t switch from a name brand medication to a generic version.

Browsing information about brand names and generics, you’ll hear a typical line which isn’t telling the whole story. Is there a difference? No (they say), you just pay more for the brand name because the big drug company is paying for their fancy advertising.

Now I’m not about to paint all drug companies with the same brush – all as great heroes of our time, or as health care villains. But this simple answer just doesn’t fit all the facts.

One look at a generic medication beside a brand name will tell you right away that there are some differences, because the two probably won’t look the same. So what actually is the difference?

Generic drugs will have different “fillers” (exipients), such as colouring. Now generally speaking, this will make little or no difference to you.

Why? Because your generic medication is probably going to act exactly the same way in your body. The active ingredient is the same, it will be absorbed at the same rate, it will work the same way. That is generally the legal requirement.

However, those tiny differences can make a difference for some people, especially in certain medications. For example, what about generic triptans vs namebrand? For most people, all they will do is save money. But for others, one may actually work better than the other.

That being said, it could be the generic that works better.

If you’re switching to a generic, and you find it works well, try to stay with the same generic medication. There are differences between generics as well.

What about the claim that you’re just paying for big company advertising? Again, it’s not so simple. Although the system is far from perfect, it is designed to help the companies that research the medication get their investment back, enabling them to continue research into new medications.

In the United States, there has been another legal concern about generics. Because they are not the ones doing the research, and are only copies of the original, they aren’t necessarily required to keep you up to date with the latest safety concerns. In other words, if a generic drug harms you and you want to file a lawsuit, the generic company won’t have the same responsibility as the brand name drug company.

To explain further, here are a couple of videos. The first explains how a drug comes into being and goes from brand name to generic. The second is a brief discussion from Harvard Medical School about the differences.

20 August 2015

Are we ruling out hemicrania continua too soon?

James Information, Medications, Tips 3

You’ve had a headache for weeks – then months – it may get better or worse, but it rarely (if ever) goes away completely.

It’s a one-sided headache, and some strange symptoms go along with it. Flushing or sweating in the face, congestion, watery eyes, feeling restless. A sensitivity to light or noise.

Are we missing hemicrania continua? Part of the problem is that sometimes the symptoms play tricks on you. They may look a lot like migraine symptoms. Or they may not look like hemicrania continua (HC) symptoms – for example, a key diagnostic criteria, that HC is pain on one side of the head, seems to be almost always but not always the reality.

But there is another concern that neurologist Dr. Randolph W. Evans has. In his recent article Migraine Mimics, he suggests that some doctors may not be using the typical HC treatment properly.

HC is one headache condition that is diagnosed by treatment. It always responds to indomethacin. When the patient takes indomethacin, the headaches go away, and the diagnosis of hemicrania continua is confirmed.

But there is a catch. How much indomethacin should the patient take, and for how long? Could it be that some doctors are not raising the dosage high enough?

Dr. Evans mentions one case in which a woman had tried indomethacin for five months – surely a long enough trial. The problem was, the dosage was too low.

Missing a diagnosis by a few milligrams is pretty frustrating, especially considering that it’s not unusual for a patient to go through several doctors and wait 5-10 years for a proper diagnosis.

Indomethacin is a nonsteroidal anti-inflammatory drug (NSAID), and doctors are right to start on a low dose. Side effects can include abdominal pain, nausea, and diarrhea to name a few.

Dr. Evans suggests that doses as low as 25-50mg a day can be effective for some patients. Some patients may go up to a high dose, but be able to taper off down to about 60mg.

One specific suggestion is to try going from 75mg to 150mg to 225mg, trying each dosage for 5 days. Patients will often split the daily dose throughout the day.

Although the usual recommendation is to try up to 225mg (for example, 75mg 3x daily), there are some reports of patients responding to 300mg/day.

Because indomethacin can help us get a clear diagnosis, even if the patient can’t continue taking it, doctors should be cautioned not to stop raising the dose too soon. If the patient is able to get rid of the headache, but can’t tolerate the medication, there are other options to try.

Hemicrania continua is so often misdiagnosed, it may be more common than we think. This may be a simple way to catch cases and provide better treatment.

17 August 2015

Botox for Migraines: Will it work when other treatments don’t?

James Discoveries & Stats, Medications 1

Are patients who take Botox for migraines actually improving in the real world? In other words, are their migraine attacks actually decreasing, and is their quality of life improving? And what about patients that don’t respond well to other treatments?

Dr. Modar Khalil at the Hull Royal Infirmary in the UK has been studying headache disorders for a number of years, and most recently the use of Botox (OnabotulinumtoxinA) for migraine. His latest Botox study followed 465 patients treated in England for migraine.

It’s important to note who these patients were. First, they had a median history of four years with chronic migraine. They averaged 15 migraine attack days per month and 27 headache days. And 97% had already tried three or more preventative treatments without success.

So these aren’t people who occasionally get a headache, these are patients whose lives are seriously and constantly affected by migraine.

The best outcome was for 21% of patients, who had at least a 50% reduction in headache days in the first month after treatment, at least a 50% reduction in migraine days, and double the “crystal clear” days with no headache or migraine symptoms.

59% of patients at least hit one of these targets. botox-for-migraines-khalil

The best results came for those with 21-25 headache days per month – 74% reached at least one goal. Those with more headache days seemed harder to treat (although there was still significant improvement), and those with fewer headache days had less drastic results.

A third of the patients had a 75% reduction in either headache or migraine attack days, and at least three times the “crystal-clear” days.

The medication was tolerated well – the most common problems were a stiff neck (16%) and pain at the injection site (15%) lasting more than 24 hours.

Here are some important things you may want to note about this study. First, these results are very good considering that these are hard-core patients who have had trouble finding treatments that help. At the same time, this was a study of patients in the “real world” – helpful because it shows that Botox actually helps real patients in a normal situation. However, without controls, and without a longer period of time, it is difficult to compare statistically between patients who took Botox and those who tried another treatment, or nothing, or a sham treatment. The numbers would probably be less impressive in a controlled study.

Still, taken along with what we hear in the “real world” about the benefits of Botox (I just received another email from a patient who has been helped significantly by Botox treatment), it should encourage the community to keep pursuing and improving Botox for migraines treatment, and consider its benefits for other chronic headache disorders.