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Thursday, February 12, 2009

Headache, migraine-Are Tension headaches treatable and preventable ?

Sometimes, the cure is worse than the disease. Sometimes, the cure is the disease.

Four percent of Americans suffer headaches daily, and scientists have suspected culprits as diverse as undiagnosed jaw disorders, genetic susceptibility and stress. But according to recent research, a sizeable and growing number of headaches are being caused by the very medications taken to alleviate them — and the problem is far more common than scientists had realized. Half of chronic migraines, and as many as 25 percent of all headaches, are actually “rebound” episodes triggered by the overuse of common pain medications. Both prescription and over-the-counter drugs may be to blame.

Patients begin by popping too many pills to deal with a migraine or a simple tension-type headache. When the medications stop, another headache follows, similar to a hangover. Sufferers race again to the medicine cabinet, and before long they are locked in a cycle of headaches and overmedication.

At any given time, more than three million Americans are suffering from headaches they are inflicting on themselves, according to Dr. Stephen D. Silberstein, a professor of neurology and director of the Jefferson Headache Center at Thomas Jefferson University in Philadelphia. “If a patient’s headaches have grown markedly worse or more frequent, the problem is almost always medication overuse,” Dr. Silberstein said.

The International Headache Society last year published revised criteria to help doctors recognize and treat headaches from medication overuse. Signs of trouble include headaches that occur 15 or more days a month, according to the society, along with the heavy use of pain medications for three months or more. Overuse is defined as taking pain medication for 15 or more days a month.

“Overuse has less to do with how many pills you take to relieve a single headache than with how often you take them,” said Dr. Robert Kunkel, a headache specialist at the Cleveland Clinic Headache Center. “If you get more than two headaches a week and take pain pills for them, you’re at risk.”

The only way to know whether medication is contributing to your headaches is to stop taking them. Unfortunately, it can take as long as two months for medication-dependent patients to see an improvement.

Migraine sufferers seem to be especially susceptible to rebound episodes. Many doctors begin weaning these patients off painkillers by prescribing drugs to help prevent attacks, then gradually reducing doses of the painkillers used to treat acute episodes.

Several drugs have been approved to prevent migraines. The most recent is topiramate (Topamax), which studies suggest may lessen the frequency of attacks for up to 14 months. In addition, early trials suggest that Botox injected into the scalp can prevent or reduce the frequency of both migraines and tension headaches.

(Although not yet approved by the Food and Drug Administration for headaches, botulinum toxin is being offered by a growing number of headache clinics. When it works — which is by no means certain — it can provide relief for up to three months.)

Tension headaches can frequently be prevented with stress reduction techniques and avoidance of certain triggers. With close attention to prevention, sufferers should not need to resort to painkillers often enough to risk rebounding.

Yet almost any kind of pain pill can cause rebound problems if used to excess. Among over-the-counter drugs, those with caffeine, like Excedrin, are the likeliest villains, studies show. Among prescription drugs, triptans are most commonly associated with rebounding, Dr. Silberstein said.

But in terms of both rebound and dependence, the most problematic drugs are those containing butalbital, a barbiturate. Two such medications, Fioricet and Fiorinal, have been banned in Germany because they so often led to medication-related headaches. Both are still prescribed in the United States.

Now that research has begun to spotlight the extent of the problem of medication-overuse headaches, more and more doctors on are on the lookout for signs of trouble. “Believe me, a lot of patients don’t want to hear that they have to stop taking their pain pills in order to get relief,” Dr. Kunkel said. “But for these kinds of headaches, that’s really the only solution.”

Once weaned from medicine, most patients show significant improvement after three months. They also learn their lesson and steer clear of overusing pain pills, research shows. In one study, 87 percent continued to report significant improvement two years after stopping overusing painkillers. Many headache sufferers have been praying for a miracle cure. Now it’s here, though it may not be what they expected.

Treatment of headache-general facts.

Treatment

Not all headaches require medical attention, and many respond with simple analgesia (painkillers) such as paracetamol/acetaminophen or members of the NSAID class (such as aspirin/acetylsalicylic acid or ibuprofen).

In recurrent unexplained headaches, healthcare professionals may recommend keeping a "headache diary" with entries on type of headache, associated symptoms, precipitating and aggravating factors. This may reveal specific patterns, such as an association with medication, menstruation or absenteeism or with certain foods. It was reported in March 2007 by two separate teams of researchers that stimulating the brain with implanted electrodes appears to help ease the pain of cluster headaches.
Prevention
Some forms of headache, such as migraine, may be amenable to preventative treatment. On the whole, long-term use of painkillers is discouraged as this may lead to drug induced headaches and "rebound headaches" on withdrawal. Caffeine, a vasoconstrictor, is sometimes prescribed or recommended as a remedy or supplement to pain killers in the case of extreme migraine. This has led to the development of paracetamol/caffeine analgesic.
Petasites, magnesium, feverfew. riboflavin, CoQ10, and melatonin are "natural" supplements that have shown some efficacy for migraine prevention; a 2006 review tentatively ranked petasites and magnesium with the best evidence, and melatonin with by far the least. Adverse events included sore mouth and tongue (including ulcers) and abdominal pain for feverfew.[5]
Manual therapy
Headache sufferers often use manual therapy, such as spinal manipulation, soft tissue therapy, and myofascial trigger point treatment. A 2006 systematic review found no rigorous evidence supporting manual therapies for tension headache.[6] A 2005 structured review found that the evidence was weak for effectiveness of chiropractic manipulation for tension headache, and that it was probably more effective for tension headache than for migraine.[7] A 2004 Cochrane review found that spinal manipulation may be effective for migraine and tension headache, and that spinal manipulation and neck exercises may be effective for cervicogenic headache.[8] Two other systematic reviews published between 2000 and May 2005 did not find conclusive evidence in favor of spinal manipulation.

Spinal manipulation is associated with frequent, mild and temporary adverse effects,[10] including new or worsening pain or stiffness in the affected region.[11] They have been estimated to occur in 34% to 55% of patients, with 80% of them disappearing within 24 hours.[12] Spinal manipulation, particularly on the upper spine, can also result in complications that can lead to permanent disability or death.[10] The incidence of these complications is unknown, due to high levels of underreporting and to the difficulty of linking manipulation to adverse effects such as stroke, a particular concern.[10] Vertebrobasilar artery stroke is statistically associated with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions.[13] Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy (whether chiropractic or not) and vertebrobasilar artery stroke.[14]

Other kinds of vascular headaches include cluster headaches, which are very severe recurrent short lasting headaches, often located through or around either eye and often wake the sufferers up at the same time every night. Unlike migraines, these headaches are more common in men than in women.
Muscular (or myogenic) headaches appear to involve the tightening or tensing of facial and neck muscles; they may radiate to the forehead. Tension headache is the most common form of myogenic headache.
Cervicogenic headaches originate from disorders of the neck, including the anatomical structures innervated by the cervical roots C1–C3. Cervical headache is often precipitated by neck movement and/or sustained awkward head positioning. It is often accompanied by restricted cervical range of motion, ipsilateral neck, shoulder, or arm pain of a rather vague non-radicular nature or, occasionally, arm pain of a radicular nature.
Traction/inflammatory
Positron emission tomography functional imaging shows activation of specific brain areas duringa cluster headache.
Traction and inflammatory headaches are symptoms of other disorders, ranging from stroke to sinus infection. Specific types of headaches include:
Tension headache
Migraine
Idiopathic intracranial hypertension (headache with visual symptoms due to raised intracranial pressure)
Ictal headache
Cluster headache
"Brain freeze" (also known as: ice cream headache)
Thunderclap headache
Vascular headache
Toxic headache
Coital cephalalgia (also known as: sex headache)
Hemicrania continua
Rebound headache (also called medication overuse headache, abbreviated MOH)
Red wine headache
"Spinal headache" (or: post-dural puncture headaches) after lumbar puncture or related procedure that will lower the intracranial pressure
Withdrawal (caused by medication or other dependency creating substance removal/cessation)
Hangover (caused by heavy alcohol consumption)

A headache may also be a symptom of sinusitis.

Like other types of pain, headaches can serve as warning signals of more serious disorders. This is particularly true for headaches caused by inflammation, including those related to meningitis as well as those resulting from diseases of the sinuses, spine, neck, ears, and teeth.

A headache -What is it?

A headache (cephalalgia in medical terminology) is a condition of pain in the head; sometimes neck or upper back pain may also be interpreted as a headache. It ranks amongst the most common local pain complaints and may be frequent for many people.

The vast majority of headaches are benign and self-limiting. Common causes are tension, migraine, eye strain, dehydration, low blood sugar, hypermastication and sinusitis. Much rarer are headaches due to life-threatening conditions such as meningitis, encephalitis, cerebral aneurysms, extremely high blood pressure, and brain tumors. When the headache occurs in conjunction with a head injury the cause is usually quite evident. A large percentage of headaches among women are caused by ever-fluctuating estrogen during menstrual years. This can occur prior to, or even during midcycle menstruation.

Treatment of an uncomplicated headache is usually symptomatic with over-the-counter painkillers such as aspirin, paracetamol (acetaminophen), or ibuprofen, although some specific forms of headaches (e.g., migraines) may demand other, more suitable treatment. It may be possible to relate the occurrence of a headache to other particular triggers (such as stress or particular foods), which can then be avoided.
The most common type of vascular headache is migraine. Migraine headaches are usually characterized by severe pain on one or both sides of the head, an upset stomach, and, for some people, disturbed vision. It is more common in women. While vascular changes are evident during a migraine, the cause of the headache is neurological, not vascular. After migraine, the most common type of vascular headache is the "toxic" headache produced by fever.
Diagnosis

While, statistically, headaches are most likely to be harmless and self-limiting, some specific headache syndromes may demand specific treatment or may be warning signals of more serious disorders. Some headache subtypes are characterized by a specific pattern of symptoms, and no further testing may be necessary, while others may prompt further diagnostic tests.

Headache associated with specific symptoms may warrant urgent medical attention, particularly sudden, severe headache or sudden headache associated with a stiff neck; headaches associated with fever, convulsions or accompanied by confusion or loss of consciousness; headaches following a blow to the head, or associated with pain in the eye or ear; persistent headache in a person with no previous history of headaches; and recurring headache in children.

The most important step in diagnosing a headache is for the physician to take a careful history and to examine the patient. In the majority of cases the diagnosis will be a "primary headache" which means that the headache, whilst unpleasant is not occurring as a manifestation of a more serious condition. The main types of primary headache are tension headache, migraine, and the trigeminal autonomic cephalalgias of which cluster headache is an example. As it is often difficult for patients to recall the precise details regarding each headache, it is often useful for the sufferer to fill-out a "headache diary" detailing the characteristics of the headache. When the headache does not clearly fit into one of the recognized primary headache syndromes or when atypical symptoms or signs are present then further investigations are justified.[1] Computed tomography (CT/CAT) scans of the brain or sinuses are commonly performed, or magnetic resonance imaging (MRI) in specific settings. Blood tests may help narrow down the differential diagnosis, but are rarely confirmatory of specific headache forms.

In 2008 the American College of Emergency Physicians updated their guidelines on the evaluation and management of adult patients who have a nontraumatic headache of acute onset.

Tuesday, February 10, 2009

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What is the most important information I should know about acetaminophen, butalbital, and caffeine?
Do not use this medication if you have used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days. Serious, life-threatening side effects can occur if you take acetaminophen, butalbital, and caffeine before the MAO inhibitor has cleared from your body. Do not take more of this medication than is recommended. An overdose of acetaminophen can cause damage to your liver. Do not use any other over-the-counter cough, cold, allergy, or menstrual pain medication without first asking your doctor or pharmacist.

Why is Fioricet prescribed?

Why is Fioricet prescribed?

Fioricet, a strong, non-narcotic pain reliever and relaxant, is prescribed for the relief of tension headache symptoms caused by muscle contractions in the head, neck, and shoulder area. It combines a sedative barbiturate (butalbital), a non-aspirin pain reliever (acetaminophen), and caffeine.
Most important fact about Fioricet

Mental and physical dependence can occur with the use of barbiturates such as butalbital when these drugs are taken in higher than recommended doses over long periods of time.
How should you take Fioricet?

Take Fioricet exactly as prescribed. Do not increase the amount you take without your doctor's approval.
If you miss a dose...
Take it as soon as you remember. If it is almost time for your next dose, skip the one you missed and go back to your regular schedule. Never take 2 doses at the same time.
Storage instructions...
Store at room temperature in a tight, light-resistant container.
What side effects may occur?

Side effects cannot be anticipated. If any develop or change in intensity, inform your doctor as soon as possible. Only your doctor can determine if it is safe for you to continue taking Fioricet.
Side effects may include:
Abdominal pain, dizziness, drowsiness, intoxicated feeling, light-headedness, nausea, sedation, shortness of breath, vomiting
Why should Fioricet not be prescribed?

If you are sensitive to or have ever had an allergic reaction to barbiturates, acetaminophen, or caffeine, you should not take this medication. Make sure that your doctor is aware of any drug reactions that you have experienced.

Unless you are directed to do so by your doctor, do not take this medication if you have porphyria (an inherited metabolic disorder affecting the liver or bone marrow).
Special warnings about Fioricet

Fioricet may cause you to become drowsy or less alert; therefore, driving or operating dangerous machinery or participating in any hazardous activity that requires full mental alertness is not recommended until you know your response to this drug.

If you are being treated for severe depression or have a history of severe depression or drug abuse, consult with your doctor before taking Fioricet.

Use this drug with caution if you are elderly or in a weakened condition, if you have liver or kidney problems, or if you have severe abdominal trouble.
Possible food and drug interactions when taking Fioricet

Butalbital slows the central nervous system (CNS) and intensifies the effects of alcohol and other CNS depressants. Use of alcohol with this drug may also cause overdose symptoms. Avoid alcoholic beverages while taking Fioricet.

If Fioricet is taken with certain other drugs, the effects of either could be increased, decreased, or altered. It is especially important to check with your doctor before combining Fioricet with the following:
Antihistamines such as diphenhydramineDrugs known as monoamine oxidase inhibitors, including the antidepressants phenelzine and tranylcypromineDrugs to treat depression such as amitriptylineMajor tranquilizers such as chlorpromazine and haloperidolMuscle relaxants such as cyclobenzaprineNarcotic pain relievers such as propoxypheneSleep aids such as triazolamTranquilizers such as alprazolam and diazepam
Special information if you are pregnant or breastfeeding

If you are pregnant or plan to become pregnant, inform your doctor immediately. Fioricet can affect a developing baby. It also appears in breast milk. If this medication is essential to your health, your doctor may advise you to discontinue breastfeeding your baby until your treatment is finished.
Recommended dosage for Fioricet

ADULTS

The usual dose of Fioricet is 1 or 2 tablets taken every 4 hours as needed. Do not exceed a total dose of 6 tablets per day.

The usual dose of Esgic-Plus is 1 tablet every 4 hours as needed. Do not take more than 6 tablets a day.

CHILDREN

The safety and effectiveness of Fioricet have not been established in children under 12 years of age.

OLDER ADULTS

Fioricet may cause excitement, depression, and confusion in older people. Therefore, your doctor will prescribe a dose individualized to suit your needs.
Overdosage

Symptoms of Fioricet overdose can be due to its barbiturate or its acetaminophen component.
Symptoms of barbiturate poisoning may include:
Coma, confusion, drowsiness, low blood pressure, shock, slow or troubled breathing

Overdose due to the acetaminophen component of Fioricet may cause kidney and liver damage, blood disorders, or coma due to low blood sugar. Massive doses may cause liver failure.
Symptoms of liver damage include:
Excess perspiration, feeling of bodily discomfort, nausea, vomiting

If you suspect an overdose, seek emergency medical treatment immediately.

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Fioricet. Main Information.

Fioricet

Generic Name: acetaminophen, butalbital, and caffeine (oral) (a seet a MIN oh fen, bue TAL bi tal, and KAF een)
Brand Names: Anolor 300, Dolgic LQ, Esgic, Fioricet, Geone, Margesic, Medigesic, Repan, Zebutal

What is acetaminophen, butalbital, and caffeine?

Acetaminophen is a pain reliever and fever reducer.

Butalbital is in a group of drugs called barbiturates. It relaxes muscle contractions involved in a tension headache.

Caffeine is a central nervous system stimulant. It relaxes muscle contractions in blood vessels to improve blood flow.

The combination of acetaminophen, butalbital, and caffeine is used to treat tension headaches that are caused by muscle contractions.
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What is fioricet. main facts

Fioricet and Esgic are brand name drugs made from a combination of butalbital (a barbiturate, 50 mg), acetaminophen (325 mg), and caffeine (40 mg). They are indicated for the treatment of tension headaches and muscle contraction headaches. Although not indicated, they are commonly used to treat migraines and other pain related ailments. Note that Fioricet (and some other pain medications) are implicated as causing repeat headaches with over-use (see NYT citation below)
Fioricet is indicated for the treatment of complex and muscle contraction headaches. It is also commonly prescribed for migraines although it is not FDA indicated for this use. The usual adult dose is 1-2 tablets every four hours as needed, not exceeding six tablets in a 24 hour period.
Mechanism of action
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Fioricet is a brand name for a combination drug used to treat tension headaches, migraines, and sometimes other types of pain (although Fioricet is not expressly labeled as a general pain reliever). Fioricet is available only with a doctor's prescription, but if you are under a doctor's care for tension-related headache problems, it might be worth talking to your doctor about the possibility of using Fioricet to control your recurring or serious headaches.

Do not use Fioricet if you have used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days. Serious, life-threatening side effects can occur if you take Fioricet before the MAO inhibitor has cleared from your body. Do not take more of Fioricet than is recommended. An overdose of acetaminophen can cause damage to your liver. Do not use any other over-the-counter cough, cold, allergy, or menstrual pain medication without first asking your doctor or pharmacist. If you take certain products together you may accidentally take too much of a certain drug. Read the label of any other medicine you are using to see if it contains acetaminophen or caffeine. Avoid drinking alcohol. It can increase the risk of liver damage while you are taking acetaminophen. If you drink more than three alcoholic beverages per day, do not take acetaminophen without your doctor's advice, and never take more than 2 grams (2000 mg) per day.

Take Fioricet exactly as prescribed by your doctor. Do not take it in larger amounts or for longer than recommended. Follow the directions on your prescription label. Tell your doctor if the medicine seems to stop working as well in relieving your pain.
Take the medicine with food or milk if it upsets your stomach. An overdose of acetaminophen can cause serious harm. The maximum amount of acetaminophen for adults is 1 gram (1000 mg) per dose and 4 grams (4000 mg) per day. Taking more acetaminophen could cause damage to your liver. One tablet may contain up to 750 mg of acetaminophen. Know the amount of acetaminophen in the specific product you are taking. Store Fioricet at room temperature away from moisture and heat.

Keep track of how much medicine has been used from each new bottle. Butalbital is a drug of abuse and you should be aware if any person in the household is using this medicine improperly or without a prescription.

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. Stop using Fioricet and call your doctor at once if you have any of these serious side effects:

- fast, pounding, or uneven heartbeat;
- feeling light-headed or short of breath;
- nausea, stomach pain, low fever, loss of appetite, dark urine, clay-colored stools, jaundice (yellowing of the skin or eyes); or
- easy bruising or bleeding, unusual weakness, fever, chills, body aches, flu symptoms.

There are a number of side-effects associated with Fioricet use, and very rarely allergic reaction may occur. Side-effects of Fioricet may include vomiting, nausea, abdominal pain, anxiety, nervousness, shaking/tremor, lightheadedness, dizziness, drowsiness, or shortness of breath. Some of these side-effects may actually be signs of misuse, dependency, or withdrawal, and should be reported to your doctor. Severe side-effects can indicate an overdose of Fioricet which can be fatal; if you think you have overdosed on Fioricet, seek emergency medical help immediately. It may be necessary to come off Fioricet slowly in gradually decreasing doses to avoid negative side-effects and withdrawal; this should be discussed with the treating physician prior to stopping Fioricet.
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