Category Archives: Research

Personality Disorders: Recognition and Management in a Pain Clinic

by Larry Robins, MD

Introduction

Patients with moderate-to-severe personality disorders (PD) Are frequently seen in medical practices. It is increasingly important to recognize, limit and manage those with aggressive types of PD.  Likewise, it is crucial to recognize those who fit the bipolar spectrum. In particular, the mild end of the spectrum is often missed. The clinical stakes for missing bipolar are enormous, as these patients tend to bounce from antidepressant to antidepressant, with predictably poor results.  This article delves into recognition and management of patients whose pain treatment is complicated by psychological concerns.

Personality Disorders at a Clinic

Consider the following scenario: a 28 year old man, Bill, presents to the pain clinic with severe low back pain.  He seems angry on the first visit and is very demanding with the front office staff.  Bill tells the staff he is mistrustful of physicians.  He openly states to the doctor, “I will go back to work when you give me the right amount of drugs that help take away my pain.” Bill is upset with his last two health providers.

Over the next few months, the clinic staff bends over backwards for Bill, even though at times he is verbally abusive to the staff with a sense of entitlement.  This is demonstrated in instances such as when he calls and tells the staff: “I want to talk to Dr. Smith NOW, put me through!”  The staff, out of fear, jumps and does what he orders.  His behavior is manipulative. The physician feels as though he is in a subservient position, trying to appease Bill and end the confrontations.

When the physician recommends that Bill be evaluated by a psychotherapist, Bill laughs at the idea and refuses. Suddenly, after nine months of treatment, Bill is suddenly blaming the physician and clinic for all of his difficulties including his pain, obesity, and sexual dysfunction.  Bill threatens to sue the clinic and reports the doctor to the state regulatory office.  What happened here?

Bill was subsequently diagnosed with a paranoid personality disorder.  The clinic employees did not recognize him as having that diagnosis and failed to set limits on Bill’s behavior.  The disruptions in the usual activities of the clinic, the increased stress on the staff, and the monopolization of clinician time are difficult to quantify.  In the remainder of this article features of personality disorders that should help with identification are discussed. Optimal care and management of the disorder begins with recognition.

Approximately 10-12% of people in the general population have features of a personality disorder.1 There are a number of personality disorders, and some are more serious and difficult to treat than others.  In general, characteristics of personality disorders include: lack of insight, poor response to psychotherapy or other therapeutic interventions, difficulty with attachments and trust, a sense of entitlement, and chaotic relationships and distress with family, friends and co-workers.  Comorbid personality disorder with substance abuse is common.

Personality disorders range from mild to very severe and patients with such disorders may take on different roles, including victim, rescuer or persecutor.  When the persecutor role is assumed, the person who is the target may be in danger. Seeing a therapist for a long period of time, perhaps 5-7 years, can help to some degree.  However, goals and expectations must be limited.  Considering the plasticity of the brain is important, as some people can improve naturally over time, particularly among younger patients.   The following section describes some of the more severe personality disorder types.  However, many people do not fit neatly into any of these single categories, because they have features of two or three different personality disorders.

Paranoid Personality Disorder.  People who are diagnosed with paranoid personality disorder tends to be non-trusting, suspicious, related to seeing the world as dangerous. They may seem secretive and reluctant to confide in others.  In relationships, they view themselves as being constantly mistreated, doubt the loyalty of everybody around them, and believe they are being exploited or harmed.  Patients diagnosed with this disorder bear severe grudges against others, often, become angry easily and have a sense of entitlement.  People with paranoid personality disorders can become violent and dangerous, with many spree killers being diagnosed with paranoid personalities.  Several notorious world leaders, including Joseph Stalin and Saddam Hussein, were most likely paranoid personalities.2

Antisocial Personality Disorder.  People diagnosed with antisocial personality disorder characteristically have no regard for the rights of others.  In demeanor, they tend to be irritable, impulsive, and exploitative.  They tend to, see themselves as better or superior, and can be very opportunistic in getting what they want.  People with this disorder   have characteristics of being deceitful, stealing from people around them, and often having trouble with the law.  They frequently engage in fraudulent activities and may be successful as scam artists.  For example, a person with this disorder may take on the role of financial savior for a church, then end up stealing everything from the church.  Generally, people with this disorder have no remorse for their actions. Conduct disorder in a child often morphs into antisocial personality disorder.  Examples include fictional character Tony Soprano on the television show, and, in real life, the mafia’s “Dapper Don,” John Gotti.2

Borderline Personality Disorder (BPD).  Characteristics of people with borderline personality disorder are instability of mood, poor self-image, pervasive abandonment fears, identity disturbance and major boundary issues.  People with borderline personality disorders usually demonstrate impulsiveness, and very quick shifts from depression to anxiety to irritability.  They usually have chronic feelings of emptiness or severe loneliness, plus anger volatile tempers and even suicidal behavior. Under stress, they can become somewhat paranoid.  Coexisting problems with substance abuse or other addictive behaviors may occur, as well as sleep disorders with severe insomnia.  People with severe borderline personality disorders will react with high drama and create chaos for everybody around them.  They tend to have a split world view, which is, they see people as wonderful or terrible, with nothing in between. Borderline personality disorders can vary from mild to severe, nd become better or worse over time. Suicide becomes more likely as patients age into their upper twenties and thirties.3 Suicide is also more common within a week of discharge from a psychiatric unit. Examples of people reportedly diagnosed with borderline personality disorder include Adolph Hitler, Marilyn Monroe, and Glenn Close’s character Alex, in the movie, “Fatal Attraction.” 

Narcissistic Personality Disorder.  Narcissistic personality disorder is less common than those previously discussed and is typified by a personality in which the person sees him or herself as superior to others.  People with this personality have characteristics of grandiosity, being vain, requiring admiration, lacking empathy, having a deep sense of entitlement, having strong belief of self-importance and acting to support those feelings of self-importance.  They characteristically have behaviors which are envious, arrogant, exploitative, and can be very angry.  Examples might include General George Patton, Nicole Kidman’s character in the movie, “To Die For,” Michael Douglas’ character, Gordon Gekko, in the movie, “Wall Street.”2

There are a number of other personality disorders which are not as dangerous for the people around them or for health care providers.  Even though PD characteristics may seem extreme, they are often overlooked, and health care clinics may react by reacting to and treating these patients in a dysfunctional manner.  The difficulties begin with not recognizing the personality disorder.

Pain and Personality Disorders

One  study on people with borderline personality (BPD) concluded that BPD comorbidity with migraine is associated with increased disability from the headaches.4  In addition, in that study  those people diagnosed with BPD, were more severely affected by headaches; more inclined to be refractory to treatment; had increase in medication overuse headache; headaches were more pervasive; there was a higher degree of depression; , more unscheduled visits for acute headache treatment; and less chance of adequate response of headache medications..4

Another study indicated the incidence of BPD was increased in migraineurs.5 My recent study of 1000 migraineurs indicated that 5.5% of patients had a moderate or severe personality disorder.6 There is ample evidence that transformed migraine is associated with more prevalent psychopathology, including personality disorder, than is episodic migraine.  BPD can be considered the mental health equivalent of chronic pain.  In my experience, the two most important prognostic indicators for those with PD are impulsivity and substance abuse.

Treatment for those with PD necessitates a caring, but stern, approach.  Limits must be set on clinician contact, including telephone calls. Abuse of staff should not be tolerated.  Referral to other health care providers, particularly mental health professionals, should be suggested.  Psychotherapists and psychiatrists who are experienced with this population are vital if the patient is to be adequately managed.  Many of the PD patients do not do well with traditional, insight-oriented therapy treatment, but are better managed long-term with dialectical behavioral approach.  For a therapy to be beneficial, it must be consistent and long-term.  A psychoeducational approach may also help.  Unfortunately, even with encouragement and support many PD patients will not continue in therapy. Therapeutic goals for the PD patient are relatively modest.

It is easy to become drawn into the drama surrounding patients with PDs, particularly those with BPD.  The patient with BPD may grant the clinician power, but then subvert the therapy.  An example of this would be, “Doctor, you are the greatest, only you can help me.  These headaches ruin my life, ….and I know that nothing is going to work!”  Some clinicians are able to manage working with these patients without becoming involved in the drama and countertransference, but most do not do well working with them.  If there are signs of a dangerous PD (i.e. abuse and anger being demonstrated), during the first visit or phone call to the clinic), rather than becoming enmeshed in the relationship, is better to refer the patient to someone experienced in working with patients with PD.

There are risks inherent in caring for people who are diagnosed with personality disorders. As compared to the general population, those with BPD are at increased risk for suicide, particularly as they progress into middle age.  Identifiable risk factors for suicide among BPD patients include repeated hospitalizations (i.e. five or more), a recent psychiatric hospitalization, and, among adolescents, birth trauma.3 Certain types of PD (i.e. paranoid, narcissistic, antisocial and borderline) are more likely to become angry and vengeful with health care providers working with them; resorting to lawsuits or writing letters to the departments of regulation.  Violence may be threatened.  A patient with PD often presents as a victim, and then rapidly flips into the role of persecutor.  Anger among these patients becomes intently focused, creating a stressful environment for healthcare workers.  Setting limits and keeping careful documentation are important in these situations.

It does take a village to help a patient with a personality disorder, just as it does to adequately treat those with severe pain. It is important to recruit other clinicians, such as mental health providers, physical therapists, biofeedback therapists, etc., to aid in the treatment.

While there are no specific medications indicated for those with PD, the Axis I symptoms are more amenable to pharmacotherapy. Medications, though limited, may be beneficial for the impulsivity, aggression, self-mutilation, anxiety and depression components of PD.7   Antidepressants, mood stabilizers, and antipsychotics may ameliorate symptoms.  Some of these medications may also lessen headache pain as well.  PD patients with severe, chronic pain present additional challenges for treatment. It is important to limit and closely monitor addictive medications.  Particularly with BPD, opioids and benzodiazepines are best avoided.  The diagnosis of a moderate or severe personality disorder alters both goals and approach for pain management.

Conclusion

For patient care, it has become increasingly important to recognize those patients whose psychiatric problems complicate their treatment in a pain clinic. Patients with a personality disorder are more likely to abuse drugs, file lawsuits, or display abusive behavior toward the staff.  With personality disorders, setting limits is vital. 

Treating patients with chronic pain can be complex and challenging enough.  When their patients who live with chronic pain also have psychological comorbidities, it is vital that the psychopathology be effectively attended to, as well as the pain. 

References

  1. Lester G. Personality Disorders in Social Work and Health Care. Nashville: Cross Country University Press; 2002:28-79.
  2. Lester G. Borderline Personality Disorder. Treatment and Management That Works. Nashville: Cross Country University Press; 2005:24-25.
  3. Lester G. Borderline Personality Disorder. Treatment and Management That Works. Nashville: Cross Country University Press; 2005:15-19.
  4. Rothrock J, et al. Borderline Personality Disorder and Migraine. Headache. 2007; 47:22-26.
  5. Hegarty AM. The prevalence of migraine in borderline personality disorder. Headache.1993;33:271.
  6. Robbins L. The prevalence of personality in migraineurs. US Neurological Disease, 2007, Vol.4, Issue I.
  7. Lester G. Borderline Personality Disorder. Treatment and Management That Works. Nashville: Cross Country University Press; 2005:88-91.
  8. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th edition. Washington D.C. American Psychiatric Association: 1994.
  9. Akiskal HS. Classification, diagnosis and boundaries of bipolar disorders. Bipolar Disorder.  Edited by Maj M, Akiskal H, Lopez-Ibor J et al.  London, Wiley, 2002, pp 1-52.
  10. Merikangas KR, et al. Comorbidity of migraine and psychiatric disorders.  Neurol Clin. 1997;15:115-123
  11. Baskin SM, et al. Mood and anxiety disorders in chronic headache. Headache. 2006;46(suppl 3):S76-S87.
  12. Robbins L. Bipolar spectrum in Migraine, Cluster and Chronic Tension Headache. US Neurological Disease, 2007, Vol. 3, Issue II.
  13. McIntyre RS, et al. The prevalence and impact of migraine headache in bipolar disorder: Results from the Canadian community health survey. Headache. 2006;46:973-982.
  14. Low NC, et al. Prevalence, clinical correlates and treatment of migraine in bipolar disorder. Headache. 2003;64:53-59.
  15. El-Mallakh, et al. Antidepressants in bipolar depression, in El-Mallakh R, Ghaem S. Bipolar Depression. Washington DC, American Psychiatric Publishing, Inc.; pp149-153.
  16. Calabrese J, et al. A randomized, double-blind, placebo-controlled trail of quetiapine in the treatment of bipolar I or II depression. AM J Psychiatry. 2005;162:1351-1360.

Medication Overuse Headache: Inaccurate and Overdiagnosed

by Larry Robbins, MD

Medication overuse headache (MOH) is very frequently diagnosed; however, the MOH diagnosis is often overused. Patients are labeled as having MOH when what they actually suffer from are refractory headaches, without medication overuse (MO).   Current diagnostic criteria for MOH only require abortive medication use on 10 or 15 days of each month (depending upon the medication). 1 No evidence is needed showing that the abortive actually causes an increase in headache. MO often occurs among people with frequent headaches.  However, MO does not necessarily lead to developing increased headaches. Diagnosing MOH is not an easy task, and requires a careful assessment of the patient’s medication and headache history.  As the abortive medication was used more frequently, the headaches (usually migraines) should have also escalated in a true MOH situation. In addition, after the offending medication was withdrawn, headaches should have receded. The epidemiologic studies of MOH may not be valid, since they do not differentiate MO from MOH.

A number of years ago all abortives, including nonsteroidal anti-inflammatories (NSAIDS), were implicated in MOH. We now realize that certain medications (NSAIDS and triptans) are less likely to cause MOH than others. Opioids and butalbital compounds are the worst offenders. Although simple NSAIDS usually do not contribute to MOH, they continue to be included in the MOH criteria.

Patients often are given the label of MOH simply because they admit to regularly consuming over-the-counter analgesics or a triptan. Many patients who frequently use these medications do not suffer from MOH. There are a number of variables, including genetics, age, type of drug, etc., that help to explain why one patient suffers from MOH, while the next does not.

For many patients with frequent headaches, behavioral techniques and preventive medications (including Botox) are inadequate. Our current preventives often provide little relief, and frequently cause unacceptable side effects. We do not have any preventives that were initially developed for headache, except for the Calcitonin gene-related peptide-inhibitor  (CGRPinhibitor) injections, which will be available later in 2018.  One long-term study indicated that only about half of migraineurs found any preventive helpful for longer than 6 months. 2, 3  Declining efficacy and increased side effects often lead to discontinuation of the preventive.

Many physicians are quick to blame the patient for causing MOH. The patients are told that they are suffering from MOH due to a particular medication, even though

  1. they have only been taking that medication for a short time, 
  2. the headaches did not increase once they began the medication,
  3. medication withdrawal did not lead to a lessening of the headaches.

Physicians often instruct the patient to only use the abortive 2 days per week. The patient usually responds, “that’s fine, but what do I do the other 5 days? I have to function.” Many headache specialists and neurologists maintain a rigid posture, refusing to allow more than a bare minimum of abortive medication.  The patient either suffers or seeks help elsewhere.

Much of what is written about MO and MOH is confusing, with little basis in fact. These are arbitrary terms, without scientific validation. Of course, we must try to minimize the use of abortives. Patients on frequent abortive medication should be withdrawn for a period of time,  (easier said than done). However, many refractory patients would have zero quality of life without their (frequently used) abortives.

The current criteria conflates MO with MOH. As a result, the term MOH is wildly over-diagnosed.  This is concerning because an inaccurate label of MOH may harm the patient. Patients with the MOH diagnosis often are denied the only medication that is helpful for them.  Two alternatives seem reasonable.  We could re-define MOH, using scientifically validated criteria.  Alternatively, we could drop the term MOH altogether.  

Of course, treating those who do have MOH is never easy. Patients are reluctant to give up their abortive, whether it is Excedrin®, a triptan, or an opioid. If we can convince the person their headaches may improve via minimizing the abortive, we sometimes may succeed. There are various strategies for withdrawal.  Sometimes it “takes a village” to treat a patient with severe headaches, and we recruit other “villagers” to assist in the process. These may be physical therapists, psychotherapists, biofeedback specialists, etc.  In the long-term, at least half of those with MOH do revert back to overuse of their . 4

References

  1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33(9):629-808.
  2. Robbins,L. We Need Better Preventative Medications(Letter). Headache: The Journal of Head and Face Pain. 2001; 41(6): 611-612.
  3. Robbins,L. Efficacy of Preventive Medications for Chronic Daily Headache. Headache Quarterly. 1999; 10(3):135-139.
  4. L.  Letter in Headache, June 2001, Vol. 41, No. 6, pp. 611-612.

Migraine Treatment: A Comprehensive Guide

Migraine is a very common and disabling illness. Picking an agent that is best for each individual patient requires considering the patient’s history, lifestyle, comorbid conditions, and individual preferences.

Migraine headaches are a common cause of disability in the United States, affecting approximately 27 million American adults, or 17.1% of women and 5.6% of men. To help better define migraines, the term classical migraine has been replaced with migraine with aura and non-classical migraine is now referred to as migraine without aura. Chronic migraine, which affects 3.2 million Americans (2%), is defined as having migraine symptoms for at least 15 days per month, lasting at least 4 hours, and for longer than 3 months in duration. This is in contrast to episodic migraine, which causes symptoms on less than 15 days per month. Current treatment for chronic migraine is divided into acute, abortive agents (analgesics, triptans, ergots, etc.) and medications that will prevent migraine onset.

This review will highlight the current definitions of migraines as well as treatment options.

Migraine Characteristics
A recurring headache that is of moderate or severe intensity, and is triggered by migraine-precipitating factors, usually is considered to be migraine. Precipitating factors can include stress, certain foods, weather changes, smoke, hunger, fatigue, hormones, and so on. Migraine without aura is a chronic idiopathic headache disorder with attacks lasting 4 to 72 hours. Status migrainosis applies to migraine headaches that exceed 72 hours. Migraine features often include a unilateral location and a throbbing or pulsating nature to the pain. There may be associated nausea, photophobia, phonophobia, or dizziness. Further characteristics include a positive relationship with menses, decreased frequency during pregnancy, increased pain with physical activity, and history of migraine in first-degree relatives. It has been reported by 70 to 75% of migraine patients that they have a first-degree relative with a history of migraines.

Patients who suffer from migraines often have colder hands and feet compared with controls, and the prevalence of motion sickness is much higher in migraine patients. Although most patients will not have all of these characteristics, there are certain diagnostic criteria that have been established by the International Headache Society for the definite diagnosis of migraine. Distinguishing a milder migraine without aura from a moderate or severe tension headache may be difficult, and it is not surprising when “pure” migraine medications are effective for severe tension-type headaches.

Recurrent, repeated attacks of throbbing or severely aching headache are generally regarded as migraine, whether or not the patient has nausea, dizziness, photophobia, or phonophobia. The patient’s history is used to make the diagnosis of migraine. Physical examination and magnetic resonance imaging (MRI) or computed tomography (CT) scans are helpful only in ruling out organic pathology. Recent-onset headaches need to be investigated with an MRI scan to rule out other organic disorders, particularly brain tumors. In addition to physical exam and imaging, a check of intraocular pressure (IOP) may be warranted. With new-onset headaches, an eye exam is always warranted.

Although the pain is unilateral in 50% of migraine patients, the entire head often becomes involved. The pain may be in the facial or the cervical areas, and often will shift sides from one occurrence to another. Most patients, however, suffer the severe pain on one favored side from attack to attack.

The typical migraine patient suffers one to five attacks in a month, but many patients average less than one (episodic) or more than 10 per month (chronic). The attack frequency varies with the seasons, and many patients can identify a time of year when their headaches increase significantly. Patients with chronic migraine may have 15 days a month of headache, and many even have 30 days/month, 24/7.

The pain of the migraine often follows a bell-shaped curve, with a gradual ascent, a peak for a number of hours, and then a slow decline. Occasionally, the pain may be at its peak within minutes of onset. Many patients with migraine suffer some degree of nausea during the attack, and some experience vomiting as well. The nausea often is mild, and some patients are not bothered by it. Many patients state that the headache is lessened after they vomit. Diarrhea may occur, and is usually mild to moderate. The presence of diarrhea renders the use of rectal suppositories impossible.

Lightheadedness often accompanies the migraine, and syncope may occur. Most patients become sensitive to bright lights, sounds, and/or odors. Between migraine attacks, many patients retain the photophobia, and it is common for migraine patients to wear sunglasses most of the time. Sensitivity to bright lights is a distinctive migraine characteristic.

Pallor of the face is common during a migraine; flushing may occur as well, but is seen less often. Patients do complain of feeling excessively hot or cold during an attack, and the skin temperature may increase or decrease on the side with pain. Patients with migraines often experience tenderness of the scalp that may linger for hours or days after the migraine pain has ceased. This tenderness may actually occur during the prodrome of the migraine. Both vascular and muscular factors contribute to the scalp tenderness. Autonomic disturbances are relatively common, such as pupillary miosis or dilation, rhinorrhea, eye tearing, and nasal stuffiness. These also are symptoms of cluster headache, including the sharp pain about one eye or temple.

Alterations of mood are seen with many patients before, during, and after migraine attacks. Patients are usually anxious, tired, or depressed. They often feel “washed out” after an attack, but a calm or even an euphoric state occasionally is seen as a postdrome to the migraine. Rarely, euphoria or exhilaration may precede a migraine.

Weight gain due to fluid retention may occur, and begins prior to the onset of the migraine. At some point during the migraine, patients may experience polyuria. The weight gain is usually less than 4 lb., and is transient.

Visual Disturbances
Approximately 20% of patients experience visual neurologic disturbances preceding or during the migraine; these auras may be as disturbing to the patient as the migraine pain itself. The visual symptoms usually last 15 to 20 minutes, and most often will be followed by the migraine headache. Most migraine sufferers experience the same aura with each migraine, but occasionally one person may have several types of auras. “The light of a flashbulb going off,” is the description many patients give to describe their aura. The visual hallucinations seen most often consist of spots, stars, lines (often wavy), color splashes, and waves resembling heat waves. The images may seem to shimmer, sparkle, or flicker. These visual occurrences are referred to as photopsia.

Fortification spectra are seen much less often than photopsia. They usually begin with a decrease in vision and visual hallucinations that are unformed. Within minutes, a paracentral scotoma becomes evident and this assumes a crescent shape, usually with zigzags. There often is associated shimmering, sparkling, or flickering at the edges of the scotoma.
Patients may experience a “graying out” of their vision, or a “white out” may occur. Some patients suffer complete visual loss, usually for some minutes. Photopsia may be experienced at the same time as the gray out, white out, or visual loss.

Miscellaneous Neurologic Symptoms
Numbness or tingling (paresthesias) commonly are experienced by patients as part of the migraine. These are experienced most often in one hand and forearm, but may be felt in the face, periorally, or in both arms and legs. Like the visual disturbances, they often last only minutes preceding the pain, but the numbness may continue for hours, and at times the paresthesias are severe. The sensory disturbances usually increase slowly over 15 to 25 minutes, differentiating them from the more rapid pace seen in epilepsy.

Paralysis of the limbs may occur, but this is rare. This is occasionally seen as a familial autosomal dominant trait, and the term familial hemiplegic migraine is applied to this form. With the weakness, aphasia or slurred speech may also occur, and sensory disturbances are seen ipsilateral to the weakness. Vertigo and/or dizziness are often experienced during migraine, and may be disabling. “Migraine associated vertigo” has become a common diagnosis. At times, the dizziness is more disabling to patients than the other symptoms. Ataxia may occur, but is not common. Rarely, multiple symptoms of brain stem dysfunction occur, with the term basilar migraine being applied to this type of syndrome. The attack usually begins with visual disturbances (most often photopsia), followed by ataxia, vertigo, paresthesias, and other brain stem symptoms. These severe neurologic symptoms usually abate after 15 to 30 minutes, and are followed by a headache. This type of migraine often stops over months or years, and the patient is simply left with migraine headaches without neurologic dysfunction.

Workup for Migraine
As noted, when patients present with a long history of typical migraine attacks, and the headaches are essentially unchanged, scans of the head usually are not absolutely necessary. Whether to do any testing at all depends on the physician’s clinical suspicion of organic pathology. Sound clinical judgment, based on patient history and a physical exam, is crucial in deciding who needs which exam.

In addition to the MRI and CT scan, tests that are sometimes useful for diagnosis of headache include lumbar puncture, IOP testing, CT scan of the sinuses, and blood tests. A magnetic resonance angiogram (MRA) allows the detection of most intracranial aneurysms.

The problems that need to be excluded in a patient with new-onset migraine include sinus disease, meningitis, glaucoma, brain tumor, arteritis, subarachnoid hemorrhage, idiopathic intracranial hypertension( or low pressure headache, which is positional in nature: basically almost gone when the patient lies down), hydrocephalus, pheochromocytoma, stroke or transient ischemic attack, internal carotid artery dissection, and systemic illness.

Headache Triggers
With migraine and chronic daily headache sufferers, avoidance of triggers should be emphasized. The most common triggers are stress (both during and after stress), weather changes, perimenstruation, missing meals, bright lights or sunlight, under- and oversleeping, food sensitivity, perfume, cigarette smoke, exercise, and sexual activity. Some foods can be headache triggers, but foods tend to be overemphasized. In general, headache patients do better with regular schedules, eating three or more meals per day and going to bed and awaking at the same time every day. Many patients state that “I can tell the weather with my head”. Barometric changes and storms are typical weather culprits, but some patients do poorly on bright “sun-glare” days.

Regarding stress as a trigger, it is not so much extreme stress, but daily hassles that increase headaches. When patients are faced with overwhelming daily stress, particularly when they are not sleeping well at night, headaches can be much worse the next day.

Psychotherapy is extremely useful for many headache patients with regard to stress management, coping, life issues, family-of-origin issues, and so on. Although psychotherapy may be recommended, it is crucial to legitimize the headaches as a physical condition; headaches are not a “psychological” problem, but rather a physical one that stress may exacerbate. Once one inherits the brain chemistry for headache, these triggers come into play; without the inherited genetics, most people may have stress/weather changes/hormonal changes, but not experience a headache.

Managing stress with exercise, yoga/Pilates/meditation, etc., often will reduce the frequency of headaches. The ideal would be for the patient to take a class weekly, then do the stretches and breathing for 10 minutes a day. Patients may experience some relief from associated neck or back pain. Relaxation techniques such as biofeedback, deep breathing, and imaging also may be helpful for daily headache patients, particularly when stress is a factor.

Many migraine patients have accompanying neck pain and physical therapy may help; acupuncture or chiropractic treatments occasionally help. Certain physical therapists “specialize” in head and neck pain. Massage may be effective, but the relief is often short-lived. Temporomandibular disorder (TMD), with clenching and/or bruxing, may exacerbate migraine; with TMD, physical therapy, a bite splint, and/or Botox may help. It often “takes a village” to help a person with pain, and we recruit other “villagers”, such as physical therapists or psychotherapists.

Caffeine Use
Although caffeine can help headaches, overuse may increase headaches. Whether in coffee, caffeine pills, or combination analgesics, patients must limit total caffeine intake. The maximum amount of caffeine taken each day varies from person to person, depending on sleep patterns, presence of anxiety, and sensitivity to possible rebound headaches. In general, caffeine should be limited to no more than 150 or 200 mg a day. Some migraineurs do well by completely decaffeinating themselves; it often is worthwhile to try this approach.

Foods to Avoid
As noted, food sensitivities are not that common. Patients tend to focus on the foods, as they are a tangible trigger that one can control (as opposed to weather, for example). However, most people are sensitive to only two or three types of food in the diet. If a particular food is going to cause a headache, it usually will occur within 3 hours of eating.

Medications: Abortives
The most common first-line treatment for migraines includes triptans. More than 200 million patients worldwide have used triptans. The most effective way to use triptans is to take them early in the headache—the earlier a patient takes these agents the better the effect. Sumatriptan is an extremely effective migraine-abortive medication with minimal side effects. It is effective for approximately 70% of patients and is the gold standard in abortive headache treatment. The usual dose is one tablet every 3 hours, as needed; maximum dose, two tablets per day. However, clinicians do need to limit triptan use (ideally, 3 days per week) to avoid rebound headaches or medication overuse headache (MOH). See section on rebound/MOH.

Triptans are helpful for moderate as well as more severe migraines. Certain patients tolerate one of the triptans better than another, and it is worthwhile to try several in an individual patient. Triptans are an excellent choice for migraine patients who are not at risk for coronary artery disease (CAD). Patients in their 50s or 60s can use these drugs, but they should be prescribed cautiously, and only in those patients who have been screened for CAD. Over the 23 years that triptans have been available, serious side effects have been few; they appear to be much safer than was previously thought in 1993.

For patients who cannot tolerate triptans, there are a number of other effective non-triptan first-line approaches, including diclofenac potassium powder(Cambia), Excedrin Migraine, naproxen, ketorolac(po/IM/nasal:”Sprix nasal spray”), ibuprofen, and Prodrin (similar to Midrin, but without the sedative). We often combine 2 first-line approaches (a triptan and a non-steroidal anti-inflammatory drug (NSAID) combination, for instance).

In general, drugs containing ergotamine (also called ergots) are effective second-line therapy for migraines. They were the first anti-migraine drugs available, but they have many side effects, and at most, should be used only 2 days per week. Dihydroergotamine (DHE) is the safest ergot derivative. DHE is primarily a “venoconstrictor”, with little arterial effects. This renders it very unlikely to cause cardiac problems. Indeed, since its introduction in 1945, DHE has been remarkably safe. Intravenous DHE is a very effective migraine-abortive agent administered in the office or emergency room. Availability and cost of DHE have been a problem. Nasal (Migranal Nasal Spray) and inhaled forms of DHE (soon to be released) have been found to be safe and effective as well. Barbiturates and opioids have been studied and are effective, but because of the risk for addiction, should be used sparingly. For severe prolonged migraines, corticosteroids (oral, IV, or intramuscular) often are effective. It is important to use low doses of steroids, for only 1 to 3 days per month.

Many patients have 3 to 6 abortives on their shelf: triptan, NSAIDs, Excedrin, an anti-nausea med, and a painkiller (opioid/butalbital). They use each in different situations, for different types and degrees of headache.

A new therapy has emerged, transcranial magnetic stimulation(TMS). The patient uses a hand held device applied to the back of the head, for an acute migraine attack. The first TMS approved(in Dec., 2013) is the Spring TMS. The official indication is migraine with aura. Studies have been positive on TMS devices over a number of years. Time will tell as to the efficacy. The low-dose home TMS appears to be very safe. People rent the unit, and use 3 or 4 pulses twice daily, as a preventive. TMS may also be used abortively, but preventive use is the most promising.

Miscellaneous Approaches

Muscle relaxants (carisoprodol, diazepam) or tranquilizers (clonazepam, alprazolam) occasionally are useful, primarily to aid in sleeping. Intravenous sodium valproate (Depacon) is safe and can be effective. The atypical antipsychotics, such as olanzapine (Zyprexa) or quetiapine (Seroquel), occasionally may be useful on an as-needed basis. In the emergency room, IV administration of antiemetic agents such as prochlorperazine (Compazine, others) or metoclopramide (Reglan) may be useful. Certain preventive medications, such as valproic acid (Depakote), topiramate (Topamax), and also amitriptyline, may be useful on an as-needed basis, utilizing low doses every 4 to 6 hours. The antihistamine diphenhydramine is occasionally useful when administered intramuscularly. At times, patients may have injections for home use: ketorolac, orphenadrine, sumatriptan, diphenhydramine, promethazine, etc.

Medication Overuse Headache(MOH)
Much is written about MOH, with many patients diagnosed with this condition. Often a patient will be overusing abortive meds (medication overuse), but not be suffering “rebound/withdrawal” headaches (medication overuse, but NOT medication overuse headache). Up until recently, all NSAIDS were lumped under “meds that cause MOH”, and this simply is not true. For some patients, opioids, butalbital, and high caffeine containing meds cause MOH. Triptans are occasionally implicated as well. However, for most patients with chronic migraine, they have daily(or near-daily) headaches, the preventives may not be effective, and they use abortives in an attempt to get through the day.

There are more questions in the area of MOH than we have answers. The pathophysiology of MOH is unclear. Some patients will have MOH from 2 Excedrin daily, while others do not suffer from MOH consuming 8 per day. When patients are using frequent abortives, we often withdraw them from that abortive, push preventives, and attempt to minimize analgesics. However, for many chronic migraine sufferers, the preventives are not very effective. For those sufferers, abortives allow them to live with a reasonable quality of life.

Preventive Medications
There is no algorithm to determine who is to go on preventive headache medication. The number of monthly headaches is one factor, along with comorbidities. Patients have to be willing to take daily medication (many do not want any daily meds). There is no absolute rule that applies to headache treatment. For a patient with two headaches a month that are severe, prolonged, and not relieved by drugs, preventive medicine might be used. On the other hand, for the person who has five headaches a month, but can obtain relief from Excedrin or a triptan, preventive medicine may not be optimal. The choice of who qualifies for medication depends on the patient’s age, medical and psychiatric comorbidities, and frequency and severity of the migraine, as well as the patient’s preference. Comorbidities often determine which preventive meds are used. If a patient has HTN, a med for blood pressure will be used. When patients concurrently suffer with anxiety or depression, various antidepressants are utilized for the headache and mood disorder. We want to minimize meds, and treating 2 conditions with one medication is ideal.

In using medication, a realistic goal is to decrease the headache severity by 40% to 70%, not to completely eliminate the headaches. It is wonderful when the headaches are 90% improved, but the idea is also to minimize medication. “Clinical meaningful pain relief” is usually around a 30% improvement. Most patients need to be willing to settle for moderate improvement. Preventives may take 3 to 6 weeks to work, and “educated guesswork” often is used to find the best approach for each patient. In the long run, preventive medications are effective for approximately 50% of patients. The other 50% scramble with various abortives.

As noted, patients should play an active role in medication choice. Preventive medications should be selected depending on the patient’s comorbidities, GI system, medication sensitivities, and the like. Fatigue and/or weight gain are major reasons why patients abandon a preventive medication. Headache patients commonly complain of fatigue, and tend to give up on medications that increase tiredness. A patient’s occupation also may guide the caregiver away from certain medications; for example, an accountant may not be able to tolerate the memory problems associated with topiramate. Side effects are possible with any medication; the patient must be prepared to endure mild side effects in order to achieve results.

First-line Preventive Medications for Migraine

Botulinum Toxin A
Botulinum toxin A (Botox) has been studied extensively in patients with migraines. Nearly 4 million people have had botulinum toxin A injections for headache. Botulinum toxin A has been found to significantly improve quality of life and reduce headache impact.4 Botox is the only botlinum toxin A FDA-approved for treatment of chronic migraine. It is relatively safe and only takes a few minutes to inject. One set of injections may decrease headaches for 1 to 3 months. There also is a cumulative benefit, where the headaches continue to improve over 1 year of injections. Botox may be safer than many of the medications that are used for headache. Botox does not cause the “annoying” side effects that are commonly encountered with preventives.

Natural Supplements and Herbs
Feverfew, Petadolex (butterbur), and magnesium oxide have all proven effective in double-blind studies as migraine preventives. Of these, Petadolex has been the most effective.
Petadolex is a purified form of the herb butterbur and is made of extracted plant certified by the German Health Authority. The herb preparation is commonly used in Europe, and has been found to be successful in preventing migraines in several well-designed blind studies. The usual dose is 100mg. per day, and many increase this to 150mg. daily(all at once, or in 2 divided doses). Earlier concerns about carcinogenesis with this family of herbs have decreased with the use of Petadolex. Patients have occasionally experienced GI upset or a bad taste in the mouth, but Petadolex is usually well tolerated. It is prudent to stop it every three months or so. Petadolex is available by calling 1-888-301-1084, through www.petadolex.com., or at Amazon.com.

Magnesium helps many systems in the body to function, especially the muscles and nerves. It has been shown that magnesium levels in the brain of migraine patients tend to be lower than normal. Magnesium oxide is used as a supplement to maintain adequate magnesium in the body. A dose of 400 or 500 mg per day can be used as a preventive; tablets are found in most pharmacies. However, mild GI side effects may limit use. There are also drug interactions that may occur; as always, consult your physician. There are tablets, as well as powdered versions available.

Feverfew has been demonstrated to be mildly effective in some patients for prevention of migraine headache. Feverfew can cause a mild increased tendency toward bleeding, and should be discontinued two weeks prior to any surgery. The problem with many herbal supplements is quality control. The amount of parthenolide (the active ingredient in feverfew) varies widely from farm to farm; certain farms consistently have better quality than others. The usual dose is 2 capsules each morning; there is a liquid form available. Patients occasionally will be allergic to feverfew, and it should not be used during pregnancy. Miscellaneous herbs/supplements have been used, particularly vitamin B2. CoQ10 and fish oil have also been studied. These occasionally help, but are less effective than Petadolex.

Topiramate is an effective migraine preventive, without the weight gain commonly encountered with the other meds. While usually fairly well tolerated, common side effects include memory difficulties(“spaciness”), and tingling. In higher doses, topiramate increases the risk for kidney stones. Topiramate does decrease appetite, leading to weight loss for some patients. This anorexic effect tends to disappear after several months. The usual dose is 50 to 100mg daily, but some do well on as little as 25mg.. The dose may be pushed to 300 or 400mg. per day, in the absence of significant side effects. Topiramate is primarily used for migraine prevention, but has also been utilized for cluster and tension headache as well. Topiramate may cause a metabolic acidosis, with lower bicarbonate levels(and increased chloride). The acidosis may lead to the tingling, which sometimes is alleviated by increasing potassium-containing fruits/vegetables(or adding potassium).

Valproate, or divalproex sodium, (Depakote) is a long-time staple, popular for migraine prevention. It is usually well tolerated in the lower doses used for headaches, however, the generic may not be as effective. Liver functions need to be monitored in the beginning of treatment. Valproate also is one of the primary mood stabilizers for bipolar disorder. Oral Depakote ER (500 mg) is an excellent once-daily, long-acting agent. As with most preventives, valproate needs 4 to 6 weeks to become effective.

The β-blocker propranolol also is FDA-approved as a preventive agent for migraines. Long-acting oral propranolol (Inderal), for example, is very useful in combination with the tricyclic antidepressant amitriptyline. Dosage begins with the long-acting agent given at 60 mg per day, and is usually kept between 60 and 120 mg per day. Lower doses are sometimes effective, such as 20 mg twice a day of propranolol. Other β-blockers also are effective, such as metoprolol (Toprol XL) and atenolol. Some of these are easier to work with than propranolol because they are scored tablets, and metoprolol and atenolol have fewer respiratory effects. Depression may occur. β-blockers are useful for those migraine patients with concurrent hypertension, tachycardia, mitral valve prolapse, and panic/anxiety disorders. Bystolic (nebivolol) is another β-blocker that may be helpful for the prevention of headaches, and has fewer respiratory side effects than other agents. Bystolic probably has the least amount of side effects among the β-blockers.

As noted, amitriptyline is an effective, inexpensive agent that is useful for the prevention of daily headaches and insomnia. As a preventative agent, amitriptyline is prescribed at low doses and taken at night. Sedation, weight gain, dry mouth, and constipation are common side effects. Other tricyclic antidepressants such as doxepin and protriptyline can be effective for migraine. Nortriptyline is similar to amitriptyline, with somewhat fewer side effects. These also are used for daily tension-type headaches. Protriptyline is one of the few older antidepressants that does not cause weight gain. However, anticholinergic side effects are increased with protriptyline; protriptyline is more effective for tension headache than for migraine. Although selective serotonin reuptake inhibitors (SSRIs) are used, they are more effective for anxiety and depression than for migraine.

Naproxen is a very useful agent for the treatment of daily headaches, as well as for younger women suffering from menstrual migraine. Naproxen is nonsedating, but frequently causes GI upset or pain. Effective as an abortive, it may be combined with other first-line preventive medications. Other NSAIDs can similarly be used for migraine prevention. As with all anti-inflammatories, GI side effects increase as people age, and therefore NSAIDs are used more often in the younger population. Blood tests are needed to monitor liver and kidney function.

Second-line Migraine Preventive Therapy

There are a number of second-line migraine treatments. The anti-seizure medication gabapentin has been demonstrated to be mildly useful in migraine and tension headache prophylaxis. In a large study on migraine, doses averaged approximately 2,400 mg per day, but lower doses are usually prescribed. Some patients do well with very low doses (200 or 300 mg per day). Sedation and dizziness may be a problem; however, gabapentin does not appear to cause end-organ damage, and weight gain is relatively minimal. Gabapentin can be used as an adjunct to other first-line preventive medications. A newer drug, pregabalin (Lyrica), has a similar mechanism of action to gabapentin. Lyrica is fairly safe, but sedation and weight gain often occur.

A safe, non-addicting muscle relaxant, tizanidine is useful for migraine and chronic daily headache. Tizanidine may be used on an as-needed basis for milder headaches, or for neck or back pain. Cyclobenzaprine (10 mg) is helpful for sleeping, and helps some with migraine and chronic daily headache.

There have been a number of studies on the efficacy of using angiotensin receptor blockers (ARB) and the angiotensin-converting enzyme inhibitors (ACE’s) for the prevention of migraine. ARBs are preferred because of minimal side effects. Examples include losartan (Cozaar) and candesartan (Atacand). These may be useful for the patient with hypertension and migraine. Side effects include dizziness, among others, but they are usually well tolerated, with no sedation or weight gain.

Similar to the ARB’s, the calcium channel antagonists have been utilized for migraine prevention. Verapamil ER (extended release) is the most commonly used form, with doses ranging from 120mg daily up to 360mg. per day. Verapamil is probably more effective as a cluster headache preventive.

Polypharmacy is common in migraine prevention. Two first-line medications often are used together and the combination of two preventives can be more effective than a single drug alone. For example, valproate often is combined with an antidepressant. Amitriptyline may be combined with propranolol(or other β-blockers), particularly if the tachycardia of the amitriptyline needs to be offset by a β-blocker; this combination is commonly used for “mixed” headaches (migraine plus chronic daily headache.) NSAIDs may be combined with most of the other first-line preventive medications. Thus, naproxen often is given with amitriptyline, propranolol, or verapamil. Naproxen is employed simultaneously as preventive and abortive medication. Polypharmacy commonly is employed when significant comorbidities (anxiety, depression, hypertension, etc.) are present. Unfortunately, polypharmacy brings the risk of increased side effects.

Venlafaxine (Effexor XR) is an excellent antidepressant, occasionally helpful for the prevention of migraine. Used primarily as an SSRI at lower doses; at higher doses (100-150 mg) norepinephrine also is increased. In fact, antidepressants with dual mechanisms (serotonin and norepinephrine) are more effective for pain and headache. Another similar medication is duloxetine(Cymbalta), with typical doses being 30mg to 60mg daily. Cymbalta has several pain indications, but is probably more effective for moods than for headache.

Conclusion
Migraine is a common and disabling illness. Outside of meds, it is important for migraineurs to watch their headache triggers, and exercise regularly. Physical therapy and/or psychotherapy may be of help (“it takes a village”). There is no good algorithm for determining which medication is best. Each patient is unique, and comorbidities drive where we go with treatment. The goal is to decrease head pain, while minimizing medications. NOTE: This is an updated version of an article that appeared in the July, 2014 issue of Practical Pain Management.

 

References
Lipton RB et al on behalf of the AMPP Advisory Group. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology. 2007;68:343-349.
Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders. 2nd ed. Oxford, England: Blackwell Publishing; 2003.
Gardner KL. Genetics of migraine: an update. Headache. 2006;46(suppl 1):S19-S24.
Lipton RB, Varon SF, Grosbert B, et al. Onabotulinumtoxin A improves quality of life and reduces impact of chronic migraine. Neurology. 2011;77(15):1465-1472.
Mathew NT, Rapoport A, Saper J, Magnus L, et al. Efficacy of gabapentin in migraine prophylaxis. Headache. 2001;41(2):119-128.
Robbins L. Robbins Headache Clinic. http://www.chicagoheadacheclinic.com

Innovation: Opioid Substance Use Disorder

by Ann Quinlan-Colwell, PhD, RN-BC, DAAPM

During 2014, patients were admitted more frequently with diagnoses of soft tissue abscesses, epidural abscesses, and endocarditis. Two common denominators, among many of these patients, were a history of self-administering opioids intravenously and now needing intravenous (IV) antibiotics for prolonged periods of time. This combination posed a challenge for health care providers who believed that it was not prudent or safe to discharge patients with a port or peripherally inserted catheter (PICC) line for IV access when the patient was known to abuse opioids intravenously.  Thus, the patients with these dual diagnoses -serious infections requiring IV antibiotics and substance use disorder- were admitted to the hospital for administration of IV antibiotics for six to twelve weeks. 

Two additional concerns arose. Many providers believed that it was important to control pain and to work with these patients, encouraging them to work toward sobriety.  In many instances this was reasonable and opportune since some of the very ill and scared patients demonstrated greater motivation to seriously consider abstinence and sobriety.  The providers consulted the Pain Management Clinical Nurse Specialists (CNS) to help control the patients’ pain while minimizing opioids and then wean the opioids to discontinuation whenever possible.      

Two cardiovascular surgeons who saw the patients with endocarditis invited a team to meet to address how to best work with the patients with endocarditis resulting from IV substance use (IVSU).  The initial group included the cardiovascular surgeons, infectious disease (ID) physician, cardiology administrator, cardiology nurse administrator, behavioral health administrator, substance abuse counselor, pharmacist, social worker, case manager and pain management CNS.  An addictionologist and community provider of buprenorphine were consulted.

Since patients were also being admitted for non-cardiac infections resulting from IVSU, the team expanded to coordinate with the medical center Code Outreach physicians.  Code Outreach is the established process through which the medical center coordinated interdisciplinary care of patients who were frequently evaluated in the emergency department (ED) and/or admitted.  Eventually, the Code Outreach team assumed primary oversight for interventions, patient care, and group activities. 

The intervention and group is now known as the Code Outreach Special Team or “COST”.  It consists of the two Code Outreach physicians, a pharmacist, the substance abuse counsellors, pain management CNSs, case management, cardiac nurse coordinator and one social worker (MSW). This MSW follows all the patients who are admitted to receive long term IV antibiotics to treat infections resulting from IVSU. Each patient in this category is reviewed weekly by the COST.  At the weekly meetings, the patients’ condition, challenges, pain management, progress toward goals, discharge needs/plans as well as the barriers to achieving these are discussed.  The plan of care is amended as needed. A template was developed for an individualized COST note to be created during the meeting and entered into the electronic medical record for the patient. This COST note is available to all professionals providing care and working with the patient. 

Each of the patients is also individually followed at least weekly by the pain management CNS, substance abuse counsellors and MSW.  The team, especially the MSW, works closely with methadone maintenance programs and providers of buprenorphine in the community to identify resources to connect with the patient prior to discharge.  While hospitalized, the substance abuse counsellors, MSW and pain management CNS work with the patients to encourage and support sobriety.  Recently, the team has located an Alcoholic Anonymous/Narcotics Anonymous group to conduct meetings for this group of patients while hospitalized. 

The pain management CNS works with the patients to control their acute pain which generally requires some opioids as part of a multi-modal analgesic plan of care (MMA-APOC).  As resolution of the acute infection resolves, the focus changes to weaning opioids and progressing to a non-opioid MMA-APOC.  Patients are encouraged to learn non-pharmacologic ways to control pain including square breathing, relaxation, distraction, and exercise.  The medical center Healing Arts Network are consulted for patients to learn tai chi and/or yoga and receive massage. 

Future plans include:

  • the MSW being dedicated full time to working with these patients
  • securing a room for the AA/NA meetings
  • identifying a physician to initiate prescription of buprenorphine for interested patients
  • developing a care plan or care trajectory that provides for consistency with room for individual care
  • educating all medical center staff about the COST, clinical note and care plan
  • increase funding for Healing Arts Network to increase support of non-pharmacologic interventions and education
  • increase interactions with community treatment and behavioral health providers and facilities
  • increase interaction and expand work with families of patients followed by the COST
  • collect and analyze data to determine effectiveness of COST activities
  • obtain grant funding to improve and formalize the COST and increase resources

The dedication and work of the member of the Code Outreach Special Team is acknowledged.

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