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Is a Placebo as Effective as Maxalt?

When the general media got hold of the study results about the efficacy of a placebo versus that of the triptan Maxalt, the reporting — and comments — inevitably became about thinking one’s way out of a migraine. Readers, and even some reporters, pointed out that of course a placebo works for migraine, but it wouldn’t work for a legitimate illness, like cancer or heart disease. Wrong, wrong, wrong!

Starting from when we learn about it in grade school, the placebo effect gets oversimiplifed to: if you think a sugar pill is effective medicine, it will provide relief. The phenomenon is far more complicated than that. The placebo effect may have a positive-thinking element to it, but it also involves complex brain activity — in the physical brain, not the thinking mind — that’s only now starting to be understood. And it has shown to have an effect for all sorts of ailments, not just those that involve subjective reporting.

The placebo effect also involves information and patient empowerment, as Diana Lee explains in Placebo Effect & Migraine: What Does the Research Mean? It’s worth reading the entire insightful piece yourself, but here’s an excerpt:

Rather than demonstrating you can think your way out of experiencing the symptoms of a migraine attack, the results support the idea that how we talk about a treatment can increase the effectiveness of that treatment by 50 percent or more…. If we know a particular medication is likely to be effective for a migraine patient and couple that knowledge with a physician/patient discussion that empowers the patient with the same knowledge, this can only benefit patients.

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Traditional & “Sham” Acupuncture Both Effective for Migraine Relief

I don’t normally republish press releases without further investigation, but I’m going to today because 1) It is from the American Headache Society and quotes my headache specialist, whom I trust immensely; 2) It provides a novel, scientific perspective on why acupuncture may help migraine (the focus is on endorphins and the effect they have on inflammation and pain signals, not the usual talk of meridians and energy flow); and 3) I have a killer migraine.

American Headache Society Supports the Use of Acupuncture in Migraine Treatment: Both Traditional Acupuncture and “Sham” Acupuncture Provide Relief

Mt. Royal, NJ (February 1, 2012) – When it comes to treating migraine, so-called “sham” acupuncture (where needles are inserted only to a superficial depth in the skin and not in specific sites) and traditional acupuncture where needles are inserted in specific sites, both are effective, according to the American Headache Society (AHS).

Citing publicity surrounding a recent Canadian study comparing the effectiveness of the two types of acupuncture, David W. Dodick, MD, AHS president, said both types of acupuncture, particularly when electrical stimulation is involved, may work to release endorphins that are important in controlling signals of pain and inflammation.

“How much of a benefit sham acupuncture can have on the release of these chemicals is unclear,” he said. “This suggests the benefits of treatment may not depend on the exact technique of acupuncture and needle positioning.”

There is ample evidence supporting the value of acupuncture in migraine treatment, Dr. Dodick noted, including four studies that compared acupuncture to standard migraine preventive medications. Acupuncture was found to be at least as effective and produced fewer side effects.  Further, he noted that a randomized clinical trial study published in November comparing acupuncture to topiramate in chronic migraine prevention showed that acupuncture was more effective than topiramate. Topiramate is an anticonvulsant often used in epilepsy.

Dr. Dodick said that needle positioning may be less relevant than acupuncturists believe, and acupuncture should be offered to patients as part of their options for migraine management.  “Further, the long-lasting effects of acupuncture, given that subjects continued to experience a reduction in migraine frequency two months after treatment, is also noteworthy and not a point to be ignored,” he said.

“Along with biofeedback training, cognitive-behavioral therapy, and lifestyle changes, acupuncture provides some migraine sufferers with a safe, non-pharmacologic treatment choice, and one that can also be used during pregnancy,” Dr. Dodick said.

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Is One of Your Medications a Placebo?

Almost half of doctors use placebos to treat patients, but only 4% are up front with patients about it, according to an American Medical Association article. Having doctors admit that they dance around the truth to get patients to agree to a medication they don’t know is a fake is troubling. It also poses ethical questions about patient-provider relationships. But…

Placebos have an important role in medical treatment. I’d be thrilled if one did the trick for me. Telling the patient that they’re getting a placebo undermines the placebo effect, thus negating the potential benefit. I wouldn’t want to know if my doctor prescribed a placebo for me — at least not at first. However, I also expect my doctors to be honest with me.

The phrases physicians used were:

  • “[It is] a substance that may help and will not hurt. “34%
  • “This may help you, but I’m not sure how it works.” 33%
  • “It is medication.” 19%
  • “It is medicine with no specific effect.” 9%
  • “It is a placebo.” 4%

The article Doctors Use Placebos But Don’t Tell Patients describes the study and the American Medical Association’s response to it.

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Placebo Effect: In the Brain, Not the Mind

Many of us learned in high school biology that the placebo effect is when you think that a treatment is effective even though the treatment or medication is an inactive form of treatment. You think you will feel better, so you believe that you are better.

High school biology was wrong. Studies using sophisticated brain scanning equipment have shown that when participants believed a medication would ease pain, the brain releases endorphins and opioids, the brain’s natural painkillers.

PET scans turned up differences in brain activity. Those who reported pain relief after taking the placebo showed increased activity in parts of the brain associated with modulating pain. A radioactive tracer also revealed that binding occurred at receptors for naturally occurring pain-fighting endorphins.

“If somebody believes something will work,” says Zubieta, “that positive expectation by itself, through different connections in the brain, activates mechanisms that suppress pain. We saw a linear relationship between how people reported pain and how their brains released opioids.

People Need Both Drugs and Faith to Get Rid of Pain is an excellent article explaining current and past placebo research and understandings.

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Following Directions for Better Health

Taking meds exactly as prescribed may have a placebo effect of its own. An analysis of 21 clinical trials shows that whether participants took the active drug or a placebo, those who took the drugs as prescribed had 44% fewer deaths than those who didn’t follow the instructions.

The author of an editorial that accompanies the study, which was published in the July 1 issue of the British Medical Journal, asserts that this is evidence of the mind-body connection of the feeling of being cared for by one’s doctors and caring for oneself.