Meds & Supplements, Treatment

Acetaminophen Safety: How Safe is Tylenol’s Active Ingredient?

Acetaminophen, the active ingredient in Tylenol, is an over-the-counter drug that many people think is benign. It’s been regarded as safe enough to use through pregnancy. As someone who used to pop large numbers of OTC painkillers each day, I’m increasingly horrified when new information comes out about the safety risks of acetaminophen. Most people don’t take high enough doses to be in danger, but people with headache disorders or chronic pain are at risk of taking too much without even knowing it. The risk isn’t necessarily in long-term use; exceeding the maximum daily dose in one 24-hour period can cause severe liver damage.

This infographic from the University of Florida’s pharmacy program highlights some of the risks and dangers of acetaminophen. If you’re concerned about your acetaminophen use, please talk to your doctor about alternatives. Some of the alternatives recommended below, like NSAIDs and opioids, also have limits to how often they should be taken; many opioids are packaged in pills that contain acetaminophen, which negates their use as an acetaminophen substitute.

(Click anywhere in the infographic for a larger, easier-to-read version.)

Community, Meds & Supplements, News & Research, Treatment

Potential Liver Damage When Combining Caffeine and Painkillers

My response to Painkillers, Caffeine May Cause Liver Damage, a post on Somebody Heal Me, was much stronger than “Oh darn.”

[P]reliminary research indicates that people who take in large quantities of painkillers containing acetaminophen [Tylenol] and ingest large amounts of caffeinated beverages may be at increased risk for liver damage. Migraine medications that intentionally mix acetaminophen and caffeine are also suspected of increasing the risk of liver damage when taken in large quantities. This would include over the counter medications such as Excedrin and prescription medications such as Fioricet. The danger is similar to that of consuming alcohol and acetaminophen, which scientists have warned about for many years.
(emphasis mine)

Knowing how effective acetaminophen and caffeine are for many people with headache, the research deserves consideration. I’m especially interested what role drinking caffeine (or eating caffeinated doughnuts) may play.

Caveat: This study used very high doses of both caffeine and acetaminophen. Still, the potential toxicity of acetaminophen — with or without caffeine — should not be overlooked. Overdoses of products containing acetaminophen account for 40 to 50% of all acute liver failure cases each year in the United States. If you ever take acetaminophen, please read Toxicity and Tylenol to understand the dangers.

Doctors, News & Research

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.

Meds & Supplements, News & Research, Treatment

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: