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Optimizing Migraine Care

Optimizing Migraine Care

The American Headache Society (AHS) recently joined the Choosing Wisely initiative of the American Board of Internal Medicine in an effort to draw attention to tests and procedures that are associated with low-value care in headache medicine. An AHS committee of headache specialists produced a list of five such tests and treatments, and their methods and rationale were published in Headache. “We wanted the list to address common but often unnecessary or potentially risky tests and treatments for headache that in many cases do not represent evidence-based strategies,” explains Elizabeth W. Loder, MD, MPH, FAHS, who was lead author of the study.   Imaging According to the AHS, neuroimaging studies should not be performed in patients with stable headaches who meet criteria for migraine. In addition, CT scans should not be used in non-emergency situations as a diagnostic tool for headache patients when MRI is available. “MRIs can diagnose more underlying conditions that may cause headache that can otherwise be missed with CT,” says Dr. Loder. In addition, MRIs do not expose patients to radiation like CT scans. The recommendations note that MRI is of better value and safer than CT for migraineurs in all but a few emergency situations.   Treatments The AHS also recommends against prescribing opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders. “The effectiveness of opioids is not in question,” Dr. Loder explains, “but these agents pose serious long-term risks and should be reserved for select patients. Effective long-term treatments will in most cases be necessary to manage this chronic disorder.” In addition, the risk of dependency and abuse associated with opioid...
Migraine & Stroke Risk

Migraine & Stroke Risk

Migraines affect more than 10% of all Americans and are three times more common in women than in men, according to data from the National Institute of Neurological Disorders and Stroke (NINDS). Although the link between migraine and stroke is not fully understood, research suggests that the two conditions have some clinical features that overlap. The NINDS has reported that risk factors for stroke with migraine-like features include being female, being older than 40, and having low cardiovascular risk profiles. Over the years, many studies have suggested that migraine is a risk factor for stroke. Some analyses have shown that stroke risks are twice as high in people who suffer from migraine with aura than those without aura. For women, stroke risks have been reported to be three times higher when they have migraine with aura. “To date, most of the research examining the link between stroke and migraine has shown that there is a correlation in migraineurs with aura,” says Teshamae S. Monteith, MD.   Taking a Deeper Look For a study published in Neurology, Dr. Monteith and colleagues aimed to determine the association between migraine and stroke and a combination of vascular events, including stroke, heart attack, and death. Participants in the study were from the Northern Manhattan Study, a population-based cohort of stroke incidence. The participants were from an older, ethnically-diverse community in which the population was predominately Hispanic, a patient group that has historically been at a higher risk for stroke. The association between migraine and the combination of vascular events was estimated over an average follow-up of 11 years. After reviewing 1,292 people who reported...
Progressive Opioid Use: Who’s At Risk?

Progressive Opioid Use: Who’s At Risk?

Throughout the United States, greater attention is being paid to accidental overdoses from the long-term use of opioids. Experts have reported that there is an urgent need to better understand patterns of opioid prescribing. In most cases, healthcare providers do not prescribe opioids with the intent of having patients use them long term, nor do they intend to provide repeat prescriptions. “Opioids are an important drug class that is used to manage short-term pain as well as pain after surgical procedures or trauma,” explains W. Michael Hooten, MD. “At the same time, it’s critical that these medications are prescribed carefully to ensure their safe use by patients.” Studies are lacking on the characteristics associated with the transition from shorter-term to longer-term opioid use, says Dr. Hooten. “When opioids are first prescribed, it’s unclear which patients are more likely to eventually receive repeat prescriptions,” he says. “A better understanding of these characteristics may help guide efforts to optimize opioid use. It could also help us anticipate the potential for inappropriate episodic or long-term use.” Exploring Recent Trends The Consortium to Study Opioid Risks and Trends (CONSORT) is an initiative supported by the National Institute of Drug Abuse that has identified trends and risks associated with long-term opioid therapy for chronic pain. CONSORT classified opioid prescribing patterns as 1) short-term use, 2) episodic use, and 3) long-term use. Dr. Hooten and colleagues had a study published in Mayo Clinic Proceedings that sought to determine how often patients receiving new opioid prescriptions progressed to episodic or long-term opioid use. It also examined associations between patient characteristics and the transition to longer-term use...
Managing Pain in Obese ED Patients

Managing Pain in Obese ED Patients

Weight-based dosing of opioids is a commonly used approach for managing patients who present to the ED with more severe pain. “Many patients who present to the ED with pain are obese or morbidly obese,” says Asad E. Patanwala, PharmD. “Heavier patients often receive larger total doses of opioids when compared with normal weight individuals. This can potentially increase the risk of serious adverse events.” He adds that morphine is one of the most commonly used opioids in EDs, but data on morphine dosing are limited among obese individuals. Studies are needed to evaluate the analgesic response to morphine, especially in patients with very high BMIs. Comparing Analgesic Responses In a study published in the Emergency Medicine Journal, Dr. Patanwala and colleagues retrospectively reviewed 300 consecutive patients who received intravenous morphine (4 mg) for pain. Patients were categorized into three groups based on their BMI: non-obese, obese, and morbidly obese. The authors then compared analgesic responses to morphine in the three groups. “Our primary goal was to see if patient weight really matters with regard to analgesic response to morphine,” Dr. Patanwala says. Using a scale of 0 being no pain and 10 being worst possible pain, the median baseline pain scores were 8.5, 8.0, and 8.5 in the non-obese, obese, and morbidly obese groups, respectively. The median analgesic response after morphine administration was 2.0, 3.0, and 2.0 in the non-obese, obese, and morbidly obese groups, respectively. In a linear regression analysis, BMI was not predictive of analgesic response. The analgesic response to a fixed dose of morphine did not appear to change as a function of BMI, says...
A Look at Opioid Use During Pregnancy

A Look at Opioid Use During Pregnancy

According to NIH data, prescriptions for opioids have increased dramatically in the general population, rising by more than 200 million between 1991 and 2009. In 2014, the American Society of Anesthesiologists distributed a list as part of the American Board of Internal Medicine Foundation’s Choosing Wisely campaign to help physicians and patients engage in conversations about treatments or medications that are commonly prescribed in pain medicine but are not always necessary. The list noted that opioid analgesics should not be prescribed as first-line therapy to treat chronic non-cancer pain. Little is known, however, about the use of opioids during pregnancy. Assessing Prevalence & Patterns of Opioid Use In a study by Brian T. Bateman, MD, MSc, and colleagues, researchers sought to define the prevalence and patterns of opioid use in a large cohort of pregnant women. Published in Anesthesiology, the study looked at data from more than 530,000 pregnant women enrolled in commercial insurance plans who delivered babies between 2005 and 2011. “We found that 14.4% of pregnant women were prescribed opioids at some point in their pregnancy,” says Dr. Bateman. “Most opioid exposures were for short courses, typically lasting less than a week.” The study also found that 5.7% of women were given an opioid in the first and second trimester, and 6.5% were given one in the third trimester. Overall, 2.2% were dispensed opioids three or more times during their pregnancy. Back pain was the most common condition for which opioids were prescribed. Other conditions included abdominal pain, migraine, joint pain, and fibromyalgia. Rates of opioid use also varied throughout the United States, with the highest occurring...
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