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Tylenol in Pregnancy Linked to ADHD in Kids?

Children of women who take Tylenol (acetaminophen) during pregnancy have a 37% increased risk of being diagnosed with ADHD and a 29% increased risk of needing ADHD medications over kids whose mothers didn’t take the drug while pregnant, according to a large-scale Danish study. This is a correlation, not proof of causation. The two factors occur together, but they could be entirely unrelated.

Scientifically, a single study showing a correlation should not be a cause for alarm. This is pregnancy we’re talking about, a time when women are extra cautious and extra worried about everything they ingest. As one of the study’s authors said,

“As a scientist, I never want to be alarmist and use one study [to make clinical decisions]. But as a woman, when I see something like that, I would be worried, and wouldn’t take Tylenol during pregnancy any more.”

For most women, this is a fine, if sometimes uncomfortable, option, but having a headache disorder complicates the issue. Not taking any medication during pregnancy could mean months of severe pain and symptoms like nausea and vomiting (which could also be problematic in pregnancy). Women are frequently told that acetaminophen (or occasionally opioid painkillers that include acetaminophen) is the only safe option. What if the safe option isn’t actually safe?

What’s the best choice — a horribly painful pregnancy or the possibility of impaired fetal development from taking medication? Whether you’re deciding if you should take painkillers or triptans, that’s a decision you can only make for yourself. Consider how a medication-free pregnancy would affect your life and talk to both your headache specialist and obstetrician about options. They are likely to give you conflicting opinions; you’ll either need to get them to talk to each other or choose the one you trust most on the issue.

The answer is never simple, is it?

Learn more about the study’s findings:

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FDA Advisory Panel Recommends Restricting Hydrocodone

The FDA is expected to tighten restrictions on painkillers containing hydrocodone, like Vicodin, following Friday’s vote by an advisory panel. Under these controls, only written (not faxed or called in) prescriptions from a doctor would be filled, no refills would be allowed, and nurse practitioners and physician assistants could not prescribe the drugs*. These same restrictions already apply to drugs containing oxycodone (including Oxycontin and Percocet). Reducing addiction to prescription painkillers is the goal of the recommendation, though experts debate whether this is an effective approach. Patient advocates argue such constraints will be an enormous burden to those who rely on these drugs for chronic pain.

Prescription drug addiction is not a trivial problem. One hundred people die every day in the US from a drug overdose and the CDC attributes most of those deaths to prescription painkillers. In 2010, about 12 million Americans reported using prescription painkillers recreationally in the previous year.

No one should have to live with the unrelenting misery of chronic pain. Because opioids can make the brain more sensitive to pain and make migraine more difficult to treat, I no longer advocate broadly for the use of opioids for headache or migraine management. In fact, the long-term efficacy and potential harmful effects of opioid use for any type of chronic pain are in question. If opioids aren’t the answer, then patients must have access to other effective therapies, drug or otherwise. Unfortunately, alternative solutions aren’t always available. Pain patients may have to pay the cost — financial as well as physical — of dragging themselves to the doctor each month for medication to manage their pain.

Is there a way to prevent drug abuse without increasing the suffering of people who live with horrible pain?

*States differ on how they implement these restrictions. Some allow doctors to write prescriptions to be filled at a future date. Some allow physician assistants and nurse practitioners to write prescriptions with the approval of a licensed physician.

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Treating Migraines with Codeine, Oxycodone or Barbiturates Increases Risk of Chronic Migraine

Treating migraine episodes with opioids or barbituates as few as eight times a month doubles the risk of developing chronic migraine. I’m in a Phenergan fog, so I’ll let the American Academy of Neurology‘s press release tell the story:

Overuse of Codeine, Oxycodone and Barbiturates Increases Risk of Chronic Migraine

People who overuse barbiturates and opioids, such as codeine, butalbital, and oxycodone, to treat migraine are at an increased risk of developing chronic migraine, according to research that will be presented at the American Academy of Neurology 60th Anniversary Annual Meeting in Chicago, April 12–19, 2008. People with chronic migraine have headaches on 15 or more days a month.

For the study, 24,000 people with headaches in the United States were surveyed about the types of medications they use to treat their headaches. From this sample of people with headache, the researchers selected those who had been diagnosed in 2005 with episodic migraine (fewer than 15 days of headache per month). Their risk of chronic migraine was then calculated based on the types of medications they used in 2005. Among those with episodic migraine in 2005, 209 people had developed chronic migraine in 2006.

The study found people who took drugs containing barbiturates or opioids for only eight days a month were twice as likely to develop chronic migraine a year later as those who didn’t take such drugs. [emphasis mine]

“People who use drugs that contain barbiturates and opioids, if only for a total of seven to eight days a month, appear to significantly increase their risk of migraine progression,” said study author Marcelo Bigal, MD, PhD, with Albert Einstein College of Medicine in Bronx, New York. “Strict limits for these types of drugs should be enforced among people with migraine as a way of preventing their migraines from becoming more frequent and more painful.”

The study found no evidence that the risk of developing chronic migraine increased among people who frequently used triptans, which are commonly prescribed drugs to treat migraine, or non-steroidal antiinflammatory drugs (NSAIDs), such as aspirin, ibuprofen and naproxen.

The study was supported by the National Headache Foundation.

Another interesting conundrum of treating pain with opioids: Opioids appear to change the brain so that the patient actually becomes more sensitive to pain. Building tolerance is not only your body getting use to the drug (called desensitization), but you actually become more sensitive to pain overall (referred to as sensitization), not just the pain that you are specifically treating. Treating Pain With Opioids has information on this research.

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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.

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Migraine Treatment News

Here’s the roundup of migraine treatments. Other news posts I’m working on are about presentations at the International Headache Society’s conference (including cluster headache news), depression and chronic pain.

Migraine Patients Who Take Triptans Report Greater Satisfaction Than Patients Taking Barbiturates or Opioids
Survey: Migraine Patients Taking Potentially Addictive Barbiturate or Opioid
Medications Not Approved By FDA as Migraine Treatments

The survey found that patients taking triptans are significantly more likely than those taking barbiturates or opioids to report that their medication works well at relieving migraine symptoms, with sixty percent of triptan patients reporting that it describes their medication “extremely” or “very” well to say it relieves their migraines symptoms completely compared with 42 percent of patients taking barbiturates and opioids.

Patients taking opioids and barbiturates for their migraines also reported a lower quality of life than patients taking triptans, according to the survey. Patients taking these drugs were twice as likely as patients on triptans to say that migraines “always” limited their ability to exercise or play sports (35% vs. 14%), engage in sexual activity (33% vs. 17%), drive a car (28% vs. 14%), spend time with family and friends (28% vs. 8%) or simply get out of the house (33% vs. 15%).

Though many patients are prescribed barbiturates and opioids for their migraines, the majority indicated that they prefer their migraine medication to be FDA approved for the disease, not addictive and have few side effects. Seven out of ten patients (72%) surveyed said it’s “extremely” or “very” important that their prescription medications not be addictive, and eight out of ten patients (79%) said it’s “extremely”
or “very” important that their prescription medication have only minor side effects. Sixty-five percent said it’s important that their migraine medication be approved by the FDA to treat the disease.

Frova for Menstrual Migraine
Endo’s Menstrual Migraine Treatment Better Than Placebo in Study

Endo Pharmaceuticals said that its Frova 2.5mg tablets reduced the frequency and severity of difficult-to-treat menstrual migraine in women when used as a six-day preventative regimen.

Predicting Botox ‘s Effectiveness
Cutaneous Allodynia Predicts Response to Botulinum Toxin Type A in Migraine Patients

Botulinum toxin type A has been reported to be effective in preventing migraine attacks in some patients but not in others.

[R]esearchers found that patients with cutaneous allodynia had experienced significant reductions (P <.01) in migraine frequency and number of headache days in response to botulinum toxin type A, whereas patients without cutaneous allodynia had no such improvement in symptoms.

[I]nvestigators concluded that cutaneous allodynia could be used to predict which migraine patients are likely to respond to prophylactic therapy with botulinum toxin.

DHE Relieves Skin Sensitivity (Allodynia)
Migraine With Skin Sensitivity Eased By Older Drug

Dihydroergotamine or DHE, an established drug for migraine, works well even when the attack is accompanied by super-sensitivity to touch or heat and cold, according to researchers.

Many migraine sufferers get relief from the newer drugs known as triptans, but these are less effective when people also have heightened skin sensitivity. This condition, called cutaneous allodynia, makes even a light touch to the face or neck feel painful.

“Unlike triptans, DHE works in the presence of allodynia, any time in the migraine attack,” lead investigator Dr. Stephen D. Silberstein told Reuters Health.

Migraine Preventives
Migraines: Symptoms Disappear With The Right Prevention

According to Greek researchers, migraine sufferers can eliminate symptoms altogether if they take higher doses of anti-migraine medicine for a longer period of time than is now customary. Another team of researchers has found that certain psychopharmaceuticals could serve as a new therapy option for persistent chronic headaches.

“In treating migraines, optimizing the effect of already available agents is at least as important a task as developing new substances.”

I’m a little wary of this article, but wanted you to know about it. Take it with a grain of salt.