HeadWise HeadWise: Volume 2, Issue - Page 32

ask the pharmacist Headache specialists say any invasive surgery comes with risks; without more data, it would be safer for migraineurs to try traditional therapies first. (NHF) and founder and director of the Headache Care Center and Primary Care Network, Inc., in Springfield, Mo. Dr. Cady would like to see more clinical trials related to plastic surgery for migraine treatment so that physicians can make scientifically based decisions involving a larger pool of information. Dr. Cady says four of his patients have undergone plastic surgery for migraine treatment and several more are in the evaluation stage for possible plastic surgery. While he did not encourage the treatment, he says he also did not stand in their way. “These are patients with extensive histories of medication failures and longstanding, disabling chronic migraine,” he says. “We’re as curious and hopeful as anyone to see how they do.” Dr. Cady says he doesn’t have any patients who are beyond the six-month mark, post-surgery. He and their surgeon are following their progress closely. RESERVATIONS AND RISKS By Richard Wenzel, PharmD Q Painkiller Problem MIGRAINE HAS BEEN VIEWED as a pain problem by many patients and health professionals in the past. Yet most migraineurs will acknowledge that pain is only one piece of the puzzle. Symptoms that accompany a migraine attack are just as intolerable as the head pain. Viewing migraine merely as a pain problem leads to unintended consequences, namely promoting the use of painkiller medications as treatment—particularly narcotic drugs (such as opioids). While narcotics can be effective at relieving pain, their ability to eliminate associated symptoms and return patients to normal function is not well proven. Further, narcotics commonly cause drowsiness, which diminishes a person’s capacity to perform daily work or household activities. Thus, these medications may not be the ideal migraine treatment option. Other research concludes that overuse of narcotics can cause episodic migraine to transform into a pattern of daily or near-daily headache. The American Academy of Neurology 2012 “Guidelines on Treating Migraine” state that opioids “may play a significant role in headache progression and patterns.” Additionally, clinicians and patients often have concerns that the use of narcotic drugs could result in patterns of medication consumption best described as dependence or abuse. As a result, the use of narcotics for migraine remains controversial—yet, these drugs continue to be used widely. Recent information from the American Migraine Prevalence and Prevention Study explored how narcotic medications are prescribed and consumed. Researchers sent questionnaires to 120,000 households across the United States. Information from a group of about 6,000 migraine respondents was analyzed. The results showed: About 30 percent of migraineurs had been prescribed a narcotic drug in the past four years, and 16 percent of those had been prescribed a narcotic medication at the time of the survey. Among individuals currently taking narcotics, about 67 percent used one narcotic agent, 20 percent used two agents, and roughly 10 percent used three narcotics. Nearly 20 percent of patients currently taking opioids could meet the clinical definition of dependence. Patients using narcotics were more likely to be unemployed, unmarried and have a lower household income when compared to individuals not using narcotics. Narcotic use was higher among women than men, and the average woman was approximately 50 years old. Patterns of non-narcotic medication use were explored. In comparison to individuals not using narcotics, the annual rate of visiting a doctor’s office was three times higher for people currently or previously prescribed narcotics. The number of headache days per month was lowest among those not using narcotics (three days) and highest among narcotic dependent patients (nine days). Further, the emergency room visitation rate was four times higher for prior narcotic users, five times higher for current users and 24 times higher among dependent patients. Whether narcotic use is a sign or cause of increased migraine severity remains an unanswered question. Until research is conclusive, narcotics should be reserved for situations when migraine-specific drugs or non-narcotic pain medications are ineffective, cause significant adverse effects or are contraindicated. In situations where prescribing a narcotic may be appropriate, patients’ overall ability to function should be regularly monitored as should their use of other medications and worsening of other illnesses. Hw RICHARD WENZEL, ogist at the Diamond Inpatient Headache Unit, Saint ADVERTISEMENT All medical treatments for chronic migraine involve a degree of risk—but the risk associated with surgery is more permanent, Dr. Cady says. Plastic surgery for migraine relief involves a multi-week recovery period as well as the potential for rare side effects such as hair loss, itching and asymmetric eyebrow movement. “The concern is that people will try this procedure before they’ve gone through appropriate diagnosis, evaluation and more traditional treatments,” he says. Experts say the best approach to migraine treatment is to work with a headache specialist who has a deeper knowledge of the pathophysiology of migraines and who has access to information on what treatments are FDA approved and have consensus in the field. Permanent procedures would likely be met with a physician’s skepticism if simpler, temporary relief can be obtained through medication. In their own statements, the NHF and the American Headache Society have also noted reservations about the surgery. “I think both of those organizations presently see this procedure as a last resort,” Dr. Cady says. Hw Have a medication-related question? Send an e-mail to info@headaches.org and we may answer it in the magazine! www.headaches.org | National Headache Foundation 35 34