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Archive for August 2016

Headache Management

Headache is a common problem

Nearly everyone knows someone who suffers with the chronic pain of headaches.  This may include tension headaches that arise during stress, migraines, or cluster  headaches. Tension headaches tend to follow a band-like distribution, and they are primarily frontal in location.  Migraine headaches are usually one-sided, and may respond to vasoconstricting drugs that make blood vessels tighten.  Cluster headaches are somewhat unique in that they can cause tearing in the eye on the side of the head affected as well as isolated congestion in that half of the nose.  There are also headaches related to excessive use of medication.  Medication overuse headache is thought to be the result of some repeated exposure to a rescue medication.

It is tempting to reach for a pharmacologic solution, but many headache syndromes can at least improve with lifestyle modification.  Among known headache triggers are alcohol,  a lack of sleep, stress, and certain foods.  For the clinician, good headache management starts with taking  a comprehensive history.  Identifiable risk factors should be modified when possible.   Patients who ingest excessive amounts of caffeine should scale back.  The same goes with alcohol, especially for those who may drink red wine (which for many is a  particularly strong headache trigger).  The importance of sleep cannot be overstated either.  While many of us can push through a hard day  on little sleep, it certainly appears that sleep quality and duration make a difference in headache frequency.

Pharmacologic management of headache

Depending on the type of headache and numbness or other associated symptoms,  more workup may be necessary.   The patient who has significant neurologic symptoms in the setting of headache may need  brain imaging to rule out  an intracranial mass or process.  Additionally the patient who suffers with frequent frontal headaches and has sinus complaints may need an evaluation by otolaryngology.  Only after these anatomic causes of headache are ruled out, should a pharmacologic strategy be considered.

The pharmacologic management of headache involves 2 major classes of drugs: Prophylactic medications that prevent headaches from starting, and abortive medications that rescue the patient after the headache has begun.  Common prophylactic medications include  beta blockers,  topiramate, and amitriptyline.  While these may be very helpful for many patients, they also have significant side effect potential.  Physicians will typically discuss these potential side effects with their patients, and this is important because the side effects can certainly influence functionality and quality of life by themselves.

Abortive medications, on the other hand,  are medications only taken after the patient feels the headache coming on.  These medications are designed to work quickly to relieve the pain from the headache.  Other than anti-inflammatories,  the most common medication in this class is the ergot derivatives.  These medications cause vasoconstriction in the head  which often relieves headaches especially those that are migraine.  This counteracts what has been observed in the study of patients with migraine which is a local dilation of the blood vessels in the head.   Of note is the risk that taking these rescue medications may increase blood pressure, and they are not recommended for patients who have suffered a previous stroke. Frequent reliance on rescue medications may in fact  lead to further headache issues.

Additional management options

There are other alternative therapies some patients report to be helpful.  Many patients have gotten good relief with acupuncture.  Routine exercise has also been shown to be beneficial in decreasing headaches.  There are other nonprescription substances that can be taken as well.  Supplemental magnesium has been shown to be helpful as well as riboflavin (vitamin B2).  These supplements should be tried by anybody who has frequent headaches after discussion with his or her physician.  Because many of these alternative therapies  have relatively benign side effects, they’re often under utilized.

Take-home points

If headaches are a common problem for you, take inventory of the things in your life that might be risk factors.   If you seek medical advice, be sure to give your health care provider a thorough history.  Often lifestyle changes will be enough to improve your headaches.   If you and your physician are discussing medications to treat headache, be sure to ask about side effects and ask about non-prescription options.

 

 

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FDA Approves New Peripheral Nerve Stimulation Device

Short-term Peripheral Nerve Stimulation for Acute and Chronic Pain

The FDA recently approved a new peripheral nerve stimulation (PNS) system called SPRINT, the latest in PNS technology.  PNS involves placing an electrode under the skin near a target peripheral nerve thought to be responsible for a patient’s pain pattern.  SPRINT is labeled for acute and chronic pain.  The electrode is connected to a battery source and can transmit an electrical current to the nerve and surrounding area, relieving acute or chronic pain.  Conventional PNS therapy involved having the device surgically implanted under the skin.  Although the stimulation is often beneficial, the surgically placed electrodes are subject to complications like migrating away from the target nerve suddenly or over time and the lifetime risk of infection.

SPRINT, conceived by SPR Therapeutics, is unique in that it can be placed under ultrasound guidance in an outpatient setting (clinic or same-day surgery) but only stays under the skin for up to 30 days.  It is then removed without requiring an incision and sustained pain relief has been observed in the studies that have been done.

This is an encouraging development for those that treat or suffer from focal peripheral nerve pain syndromes.  However, whether peripheral nerve stimulation is covered by one’s insurance plan and the extent of that coverage can vary greatly among insurance plans.

To read more about about the SPRINT device, Click here.

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