By

A Headache Specialist’s Comments

Christina Peterson, a neurologist (and migraineur), is a blog reader who leaves terrific, educational comments. I always learn a lot from her. Some of her comments on recent posts are so informative that I want to be sure you all see them.

Warnings Proposed for OTC Painkillers

This is a really important post–it can’t be overstated.

In fact, the NYT article, if anything, understates the matter. The truth is that at this time, over 50% of all liver transplants are necessary because of the medical use of acetaminophen. It’s such a big problem that even the makers of Tylenol have run a commercial asking people not to exceed the recommended amount.

Gastritis and ulcers are no fun, and most people have been made aware of the cardiac and blood clot risks of anti-inflammatories like Vioxx and Celebrex, but a lot of people tend to think that ibuprofen and acetaminophen are benign.

They aren’t.

It’s also important to know that a lot of prescription analgesics, like Vicodin, Percocet, Fioricet, Amidrin (and all their generic names), also contain acetaminophen–so don’t double up.

If you are an intermittent migraine sufferer, and not a chronic headache sufferer, a double-blind randomized controlled trial has established that acetaminophen has no role in the treatment of acute migraine. There are better options available.

Men & Women Experience Pain Differently

This is vastly oversimplified. (Well, OK, it’s a newspaper…) But I trust this blog readership to be more sophisticated than the sixth grade level general readership a newspaper shoots for. So.

Most of the studies that have recently emerged have indeed shown a difference in pain processing between men and women. The major difference is that pain processing in women fluctuates with estrogen levels. (Estrogen–it’s our theme of the week, isn’t it? 🙂

Some of the studies available are simplistic and misleading–lab animals were injected with estrogen, and pain thresholds decreased, which led researchers to conclude that therefore, women were weak, and couldn’t tolerate pain as well as men. (Can anyone say, “Researcher bias”?)

But if you think this through, it is counter-intuitive. It makes no sense. Pregnant women have very high estrogen levels–estrogen levels climb throughout pregnancy, until they are very high by the time labor begins.

And menstrually-associated headaches occur when estrogen levels are at their lowest–the day before menstruation begins is the most common day for a menstrual migraine, and that is the day for a drop in estrogen.

Dr. Nancy E.J. Berman, who has done very important research on the effects of hormones on trigeminal neurons and the effects on orofacial pain, TMD, migraine and fibromyalgia, and who won the Wolff Award this year from the American Headache Society, also wrote the chapter on “Sex Hormones” in the book, The Headaches. She has noted that migraine improves both during pregnancy, when estrogen is high, and after menopause, when estrogen is low. She feels that this suggests that it is rapid changes in estrogen and progesterone that serve as a trigger for migraine attacks.

Some studies suggest that women tolerate pain better than men when estrogen levels are higher, and less well than men when estrogen levels drop–we are still discovering whether it is the rate of drop that is critical (likely), or whether it is also the estrogen:progesterone ratio that has an effect.

Other studies have shown that postmenopausal women process pain similarly to men.

I will say this, though: when I do Botox injections in the office, it’s generally not the women who get faint on me. 😉

Birth Control Pill News

This is all well and good…if you are young, and if you do not have migraine with aura.

Please refer to the following from the ACHE website: Will Using Oral Contraceptives Increase the Risk of Stroke?

It is the standard of care amongst headache experts to advise that women with migraine with aura either not use oral contraceptives at all, or use them very judiciously and with aspirin cardiac prophylaxis, and only if there are no significant cardiovascular risk factors. It is also recommended that women who have migraine without aura discontinue oral contraceptives after age 35. Smokers who have migraine should not use oral contraceptives at all.

I recall reading a recent article that surveyed migraine sufferers, and found that a significant proportion of primary care physicians were not aware of current recommendations regarding migraine and oral contraceptives. (I cannot, however, find the article in my giant stack-of-articles-to-be-filed. So, no citation for you–sorry. I think the author was Dr. Elizabeth Loder, but Google is not bringing it up.)

There is also newer data regarding the increased risk of heart disease in women with migraine, which was published in JAMA recently.

This study looked at women over 45, but estrogens, contained in the vast majority of contraceptives, are also a cardiac risk factor.

So–if you are going to proceed with this, be certain your physician knows you are a migraine sufferer (if you are), and research your family history and personal cardiovascular risk factors.

To learn more about and from Dr. Peterson, visit her websites, Migraine Survival and Headquarters Migraine Management.

By

Warnings Proposed for OTC Painkillers

A painkiller shouldn’t be considered harmless just because it’s sold over-the-counter. A painkiller shouldn’t be considered harmless just because it’s sold over-the-counter. A painkiller shouldn’t be considered harmless just because it’s sold over-the-counter. Get my drift?

Now the FDA wants to spread the message by adding “prominently highlighted” warning labels to all OTC painkillers. Consumers will be warned that drugs containing acetaminophen can cause liver failure and those with aspirin or nonsteroidal anti-inflammatories (NSAIDs) can cause gastrointestinal bleeding.

The NY Times article points out an issue of particular interest to folks with chronic pain — and one that won’t make it to OTC drug labels:

“A recent study of liver failure in which Dr. Lee participated found that the percentage of cases related to acetaminophen overdoses had grown. Many were caused when patients with chronic pain took prescription narcotics bundled with acetaminophen. The new proposal does not address that combination.”

The brand names of the different types of OTC painkillers are many, but here are some of the most well-known. Other brand names can be found by clicking on the drug type.

For more about the proposed changes, see the FDA’s press release.

You can learn about the risks of OTC meds in the NY Times article, Medline’s pain relief section and in these previous posts:

By

Tylenol & Ibuprofen Linked to Women’s High Blood Pressure

Women who take more than 400 milligrams of ibuprofen (or other NSAIDs) or 500 milligrams of acetaminophen per day have an increased risk of high blood pressure than those who do not take the meds, found a study that will be published in the September issue of the journal Hypertension.

Taking more than 400 milligrams of NSAIDs per day increased the risk of high blood pressure by 78% in women 51 to 77 years old and by 60% in women between the ages of 34 and 53. Daily use of more than 500 milligrams of acetaminophen raised the risk of high blood pressure by 93% in women in the older age group and by 99% in younger women.

This study clarified that it is the painkillers and not the headaches that women are trying to treat that cause high blood pressure.

Learn more by reading the WebMD article, Common Pain Drugs Up High Blood Pressure Risk, or the journal article abstract, Non-Narcotic Analgesic Dose and Risk of Incident Hypertension in US Women.

By

OTC Painkillers and Heart Attack Risk

Vioxx and Bextra made big news this spring when they were pulled off the market for increasing a patient’s risk for heart attacks. A recent study indicates that OTC painkillers containing ibuprofen and naproxen also raise heart attack risks.