oh okay or do you want to stand up and stretch are you okay that was pretty short no one's bladder's full yet because if it is that's a problem okay what i want to do now is talk about the concepts of pain and the medications that we have available to us this is again a very similar condition contextually or conceptually that we have with asthma is we have many many medications that have an effect there is no way to predict who will respond to what so i'm going to go through a variety of things and just try and give you some tips and suggestions for how to think about these different medications that we have i'll spend time talking a little bit about acute pain osteoarthritis i'll talk about migraines specifically acute gout and i've got like one slide on neuropathic pain because that's about all you need to know uh about the evidence for neuropathic pain stuff so we have a variety of different types of common pain killers i would hazard to guess if i had to guess i would imagine almost every one of you have used these maybe not who's never tried tylenol or aspirin or an nsaid who's never ever had one a bunch of drug users you disappoint me i was hoping to be one i've never tried it because i remember there was one person in one of the classes who we like i said so if you had life-threatening meningitis would you take an antibiotic no okay yeah i'd rather die then no i and this is where it has nothing to do with evidence and it always becomes a it's a religion about what you would do anyway that's okay you know what perfect i have no problem with people who make those decisions but i document if i had to do that so we have a whole bunch of drugs acetaminophen we have anti-inflammatories which by the way are not very good anti-inflammatories they don't reduce inflammation really very well at all and i'll talk about that as we go over this in a bit we have a bazillion different types of nsaids um we have the cox twos there's only one left i think on the market that i'm aware of so how effective is acetaminophen for acute pain if you have post-operative pain and this could be dental pain it could be minor surgery pain that type of thing if you give acetaminophen half of participants treated with paracetamol and by the way paracetamol is acetaminophen paracetamol is the sort of european name for acetaminophen almost all or at least most of the stuff that i'm presenting to are cochrane reviews which are identified by that and this is their sort of baseline or not their baseline their their uh conclusions half a participant treated with acetaminophen at standard doses stanidoses is 500 milligrams maybe a thousand milligrams of acetaminophen achieved at least 50 pain relief over 46 hours compared with about 20 treated with placebo so the wonderful thing about acetaminophen if i give it about 50 percent of people will do well how many of those benefit from the drug versus how many people would have not didn't need it what's the difference between so 50 will get a benefit from the drug only 30 percent of those got better because of the drug for acute migraine headaches so even and this is not just your tension headache this is for people who have migraine headaches there is really solid evidence that paracetamol or acetamill is superior to placebo with numbers needed to treat a 12 5 and 5 for two hour pain relief pain two hour pain free and one and two hour headache relief respectively so you don't get everybody responding but you get one in ten are getting a benefit uh roughly speaking and here this is sort of uh one out of five are getting a benefit unfortunately we don't have products that are that much more effective but the nice thing about it is when you give drugs you're not getting just that benefit of the drug you're also getting not necessarily the placebo effect but what happens with no treatment because these headaches go away so you're going to get a response probably to most of the things that you try uh so this is again i don't want to go over this in detail other than that there is good evidence that acetaminophen works for migraine headaches so if you have a person who comes in with problem migraine headaches i'm hoping actually by the time you've seen them have they already tried this anyway but if for some reason you ever had a patient come in i've never had a migraine ever and i've never bothered to try anything we do know acetaminophen works the one place where so so there is good trial good evidence for acetaminophen for acute pain for many many conditions i just gave you some examples we also have nsaids nsaids or products like ibuprofen diclofenac naproxen all those agents and often the debate is which do you use do you use acetaminophen or nsaids chronically there is no comparison in my mind chronically nsaids are far have far more toxicities than acetaminophen acutely i don't think there's anything to choose between them they are all very equally well tolerated and i in fact tell you the truth i almost have no discussion about side effects when i'm recommending these things because i i don't know what to tell people other than i doubt very much anything will happen now they're allergic to aspirin that's a different story so what i tell people if i had to choose something for acute pain in children the evidence is slightly in favor of choosing an agent like ibuprofen over acetaminophen it is in no way definitive but if you what we do is when we're looking at evidence we use the best available evidence it doesn't mean it's definitive but if i had if i had both in my office or had if they had both at home and i had to choose one or the other i would choose ibuprofen it's not hugely different but there is a little bit difference in functional limitation and adverse effects but it depends what adverse effects you're looking at so in my mind there's a tools for practice i think that mike mike's put together on this if i had to choose one it would be an nsaid but if a parent had acetaminophen at home i'd say use that as well for any sort of acute event in children as far as adults go i don't know what to choose you could use acetaminophen how many of you just and here's here's a brilliant way to show a dose response curve how many of you have ever used tylenol just with a show of hands okay so almost all of you how many of you got relief from 325 like one regular 325. so i got four or five how many use one extra strength and it works okay how many use two of the regular strengths okay now one or two how many use two of the extra strings how many use three how many are just an acetaminophen tablet depending what state yeah so what you just showed there was a relatively pretty good dose response curve i could have not predicted that you were a two person two extra strength or whatever or three and i wouldn't know i don't even who said one you can't predict that so it's very like alcohol so you just say the correct dose of acetaminophen is somewhere between one and fifteen hundred go go crazy that was a question yeah right yeah there's a little bit that if you look at the evidence for fever control now there's a huge debate whether you should even treat fever and i don't think you necessarily treat fever i think you treat the child if they're not comfortable so that's that's so i'm treating for comfort not to reduce the fever if that makes sense if you're reducing fever it looks a little bit like ibuprofen works a little bit longer like maybe 30 minutes longer so whether that's clinically important or not so if again i had to choose one i had both in my hand and they were both equally priced i think i might go with ibuprofen but if i had no ibuprofen and i was at home with a kid i had acetaminophen i would not get in the car to drive to a drugstore to get ibuprofen and i like most of my children did you record that part like most of my children okay so when it comes to chronic pain and when i'm talking about chronic pain i'm primarily talking about osteoarthritis there is a suggestion that nsaids are slightly if more effective than acetaminophen however the absolute difference between using between the benefit between nsaids and acetamino in a minifig here as you can see is roughly speaking about ten percent so one in ten more people will get a benefit from using an nsaid versus acetaminophen for pain control i have no idea why that is but it's fairly consistent the issue is even though there's no difference in tolerability over six weeks when you talk to patients and when you review the medical literature on the use of nsaids chronically in general all of these agents are really safe however nsaids roughly speaking killed two thousand people every year in canada that's too many now if you look at how many people use nsaids it's millions and millions and millions so the risk is relatively low when i talk to family docs about this i asked them how many people have seen a person with a gi bleed from an nsaid and it's every one of them has so these it's about one percent one percent per six months maybe two percent per year chance of a severe gi bleed on an nsaid you don't see that with acetaminophen i've also asked people how many people have you seen ever have a serious adverse event from acetaminophen other than overdose and i and it's one maybe two it is so unusual it's not zero but there is no comparison in my opinion between using acetaminophen chronically and nsaids chronically if i had to use one it would be acetaminophen however if acetaminophen didn't work and an n said did work i would use the nsaid but you have an experience of someone who's got a non-overdose like yeah so you can get limit now the trick is was it caused by the acetaminophen how much they were using and so on but there have been a number of studies that have looked even in elderly people using four grams a day from months and months and months and months and months not even seeing any liver enzyme changes even anything it doesn't mean it doesn't happen but if you had to choose between an nsaid and an acetaminophen chronically i don't think there's any question about which one one you should choose and sets aren't safer you thought instead were safer yeah liver yeah oh yeah so if and i don't know if you want this you can you might want to remove this one recording if you want to kill yourself yeah acetaminophen's a brilliantly awful way to do it but when i'm talking about a c so yeah acetaminophen a dose of five pounds of acetaminophen is really bad but if you stay below that four four uh grams a day so a thousand milligrams uh four times a day now most people don't need that much yes yeah that's me that's made up to the best of my knowledge i've never been able to fi from single now if you absolutely got sloshed and you've had a history of alcoholism and your liver shot all the hell and you took a whole bunch of acetaminophen maybe but i'm not aware and reason these are all case report type things a reasonable person would not have that happen so when you have a person however one of the one of the things i'm a big fan of is there is good evidence for topical nsaids so do you guys have you guys seen the topical nsaids used yeah in your patient population yeah so i think topical nsaids there is good clinical trial evidence showing that topical nsaids especially for single joints or maybe a couple of joints topical nsaids have been shown to give as good pain relief as oral nsaids so the nice thing about it you get the pretty much a similar effect the only concern with the topical nsaids is that this the some get skin reactions to them but i would definitely definitely definitely be promoting the use of topical glands heads uh which one do you use least expensive yeah so you can get voltaire and there's over there's now uh non-prescription ones there's all sorts of different ones you can get so again you choose there's no i'm not aware of any advantage of using it in different bases whether you use different nsaids i don't think there's any difference you just try them and it's a reasonable thing to certainly try you get equivalent pain relief using topical as you do with oral whether you have acute or chronic pain so even if let's say you had a uh you sprained your ankle now i would i'm not going to suggest that you use nsaids for sprained ankles because i don't think the sports injury literature supports it but for pain relief any of those things work acetaminophen nsaids topical nsaids they all have an effect probably of the magnitude of about 20 to 30 percent above placebo uh this is just a study this is just a systematic review of the benefit of using topical nsaids there's some stuff on capsaicin but you can use it equal effect but it's really not very well tolerated from an adverse effect perspective from a topical thing yeah yeah so i i'm going to get into that into a little bit when i talk about uh sort of acute sports injury type things it used to be 20 years ago why did we use why did we use what was the reason to recommend an enzyme and then said for sports injury what's the mechanism pardon yeah they reduce inflammation how does our body heal inflammation yeah so there is no evidence to support using nsaids being better than any other painkiller for the pain associated with it there is a suggestion and the literature is not great and we had one of the sports medicine gurus in the world that are on our podcast probably a couple maybe three or four months ago nsaids are no longer you know the way you need to go with that and there's a variety of reasons one there's a potential that it may slow down healing uh the the evidence isn't clear on that it's a hypothesis it's not an unreasonable one but here's a here's just even just even think about it when you sprain an ankle what color does it usually go yeah what why does it go that color yeah it's bleeding if you had interest in your own head what drug do you not want to be on when you're bleeding well definitely warfarin uh yeah you don't want to be on a drug that affects platelets but all nsaids do actually not all of well they all do aspen is irreversible the other ones are reversible so that there's no good reason to use nsaids for the information and by the way you cannot find any studies that show you get back to that now let me rephrase that i have seen one study that shows you get back to sports faster on nsaids but i've seen a whole bunch of others that say you don't i have not been able to find a study that show they reduce inflammation which i find fascinating like just in my own mind i just go that's fascinating now not all of the rest of you are going i don't give a i find that fascinating because they're anti-inflammatories and you give them because their legs are swollen but when you actually measure they don't reduce inflammation they work a little bit better than acetaminophen for chronic osteoarthritis but there's no they don't necessarily reduce inflammation at least for cute sports injuries is that where you're going with that one yeah so the person who says they impair healing is on very shaky ground but there's a possibility uh yeah so that's just some stuff on topical nsaids i don't think i need to spend too much time on that there's there's over-the-counter products now available you can use diclofenac ketoprofen in the thing called diffusimax but talk to your local pharmacist say what do you got what should i be recommending for my patients that's that's where you should go with what one should you recommend they'll tell you what the least expensive one that they have i think i already talked a little bit about this roughly and this is not necessarily with a single dose but roughly speaking about 10 to 20 percent of patients will complain of some abdominal dyspepsia associated with an nsaid it doesn't mean they're having an ulcer it doesn't mean they're going to have a bleed tomorrow but some people will complain about it the risk of gi else's on chronic nsaid use if you and this is i always have this discussion with every patient that i recommend chronic nsaids to is yes there is a risk of ulcers if i have a patient in front of me who i would be very very nervous about causing a gi bleed so in a person who's really you know extremely elderly extremely you know they just i just know they wouldn't tolerate a a really good bleed that makes it you know what i mean by that i think you try to avoid them but the risk is one to two percent per year there are ways to prevent or reduce the chance of them you can't prevent them you can reduce the chance of them i'll talk about that as we go along but that's the risk that we're talking about i don't need to do anything with that oh enteric coding nsaids does nothing so even it's not a local effect it's a systemic effect 20 years ago i don't know if any of you were practicing 20 years ago but 20 years ago we used to entire coat every nsaid it was purely a marketing gimmick there was no evidence of benefit and it probably doesn't matter to low dose or high doses always a risk even if you're just on low doses of asthma and there's still a risk i still think you try to get them on the lowest effective dose just from a pencil perspective but there's always a risk with all of them they make platelets not so sticky so if you're bleeding you don't you know because they they have blood thinners yeah so we also have some cox 2s when they first came on the market this was this was like 10 15 years ago when biox came on the market and celebrates came on the market when celebrex came on the market uh they were promoted as being really very very safe and every new answer that comes on the market is way safer than anyone we've ever had until we use it it's it's it's unbelievably a consistent pattern so with celebrex what was really fascinating with celebrex when it came on the market is i was working with a group at the time where we evaluated all of the literature and tried to give guidance to family docs and pharmacists and naturals everybody who'd listened to us when celebrities came on the market there was not one published trial all been done being blessed studies but not one had been published so we couldn't do it we said does it work i guess it does they got on the market became the fastest selling drug of all time but not a single published trial so they appear to be equally effective no difference in overall adverse effects between the cox twos like the celebrex as you know vioxx was taken off the market no difference in kidney effects no they have no effects on cox 2 there's no effect of cox 2 on platelets so that may be an advantage but i don't think it provides a clinically important one here's the difference if you look at cox 2's versus other nsaids three studies have shown no difference in upset stomach symptoms because this was a big big thing was to use the cox twos if you have upset stomach with the aspirins and one study showed a two percent absolute difference and one showed a ten percent absolute difference so i don't know what to make of that what i can tell you is that cox twos do reduce endoscopically proven ulcers by 10 to 25 percent however they don't appear and most most of us will get endoscopically proven ulcers anyway we certainly will get them with nsaids you get less with cox 2s but you don't well with vioxx there was no reduction in gi bleeds and with celebrex or celecoxib it was probably about a half a percent absolute difference in bleeds over a year so it's not that they didn't have a little bit of uh an improvement with gi bleeds but overall bad things uh there's a suggestion that there's an increased risk of cardiovascular events which is why box was taken off the market i think the bottom line is there is no difference in overall tolerability between the cox 2s and the nsaids they are just another nsaid ah yeah here's what's important 50 patients with a gi bleed on and and then said only 16 of patients reported being informed of that adverse effect now that doesn't mean 16 were told about it because many patients will not remember what you've told them uh if they will also lie uh about whether they were told or not but a bunch of people can uh were only a few were informed about what to do if symptoms occur and unfortunately some of them had stomach pain before the bleed and all but two continued it in uh despite that so we need to have conversations about that so the common concerns about nsaids they're what we call a common cause of stomach and bowel disorders and by common i mean one percent but because we've got so many people on them you'll see a number of people who get that nsaids along with alcohol like the most common drugs to produce drug drug-induced high blood pressure and this is something really important to think about i can't give you the exact number because i don't know if i have really good numbers but anywhere from five to ten percent of patients will get sort of a a rise in blood pressure some people will complain about edema because they they do have an effect on kidneys they can cause mental confusion especially in the elderly and most importantly one of the most important things that i worry about is in heart failure so they are it is not unusual for them to worsen heart failure especially in a person who's got pretty bad heart failure so again i avoid them because they have an effect on the kidney that causes fluid retention even in otherwise healthy people so in general i just try and stay away from the nsaids i use topical answers if i can uh and one of the messages that i make sure i let people know about it is people believe that because they're on an anti-inflammatory or because they're on an nsaid that it slows down the progression of the medical condition it doesn't not in rheumatoid or osteoarthritis so the goal purely when you're using any of these medications is for pain control it's not about anything other than pain control reduction and stiffness and so on yes yeah the question is do nsaids increase cartilage destruction and so on the evidence that's out there is that pain relief increases destruction of the joint guess why because you use it more so that's that's where that sort of belief came in now why did they say n says because mainly it was nsaids being used so i don't know if it's the nsaid that's doing it it's just maybe because they're using their joints more but i don't really care because the magnitude was not big and i want these guys to have pain relief and by the way if it's a hip or a knee guess what the best treatment is replacement like hip replacements you must have seen patients with hip replacements that's one of the most brilliant surgeries you can have i mean there's always complications and i'm sure you probably see that on occasion but boy oh boy the the benefit we did a study at st paul's probably 20 years ago what we did is we looked at how how well can we control pain postoperatively in in hip replacement patients and i was surprised to find that 25 of people needed absolutely no pain relief like no morphine no anything they just when they woke up they went even though they just had their hip replaced they went oh this is so much better it's you know what would we just put your hip no it's way better because it was so painful so hip replacement knee replacements um i think are far more effective than trying to mask the pain with some sort of a painkiller so acetaminophen is painkiller has a number advantage over the nsaid it has there are some studies that are coming out a little bit to suggest they may also have a little bit of effect on blood pressure but boy it's i've only seen like maybe one trial that maybe supports that and most of the trials don't support it so i'm not i don't usually think of them as having as big an effect on the cardiovascular system they don't put people into heart failure that i've ever seen [Music] so what do you do with all these sort of painkiller processes i leave it completely up in the hands of the patient do they need to be on them regularly depends whether they get relief if you use it regularly so sometimes it may be useful to use the combination if as an example if you had really bad pain or a really bad migraine if it was me here's what i would take i would take 500 milligrams of acetaminophen 500 milligrams of ibuprofen a cup of coffee and lie down on my right side so that it empties nicely that's the best painkiller you can recommend is a combination of acetaminophen because there are studies for acute pain looking that acetaminophen the combination is better than using big doses of one so 500 to a thousand like if it's really a severe pain 500 to 1000 milligrams of acetaminophen throw in some an nsaid as a single dose and a cup of coffee because the caffeine adds another 5 or 10 benefit if you don't like coffee there are products that contain caffeine in them uh what else uh so acetaminophen is not perfect it can cause liver damage it rarely occurs except in overdose the range of doses is anywhere from 325 up to a gram four times a day so the maximum amount is eight pills of the extra strength of 500 milligram tablets per day the general recommendation is to give 2 grams if they're an alcoholic or liver disease but that's not based on really good evidence it's just if you've got a problem with your liver you probably use less and the best dose i don't need to read through all this i've already talked about all these things one of the best ways to get control of chronic pain is to take doses regularly but maybe if they only what i do is you sort of do a pain inventory ask them when is their pain at their worst that says you know it's not too bad the only time it really hurts is when i go down to the store so then what do you do what would you recommend yeah so an hour before you go to the store take a bunch of acetaminophen or so really really work it around that patient's level of pain and give them say you know it probably takes about 30 minutes to be absorbed maybe an hour to get the full effect maybe 45 minutes or so and let them figure it out and give them the dosing range that they can use you know and realizing that doubling the dose of tripling the dose of medication really gives that much more of an effect so to say most of the time you get by with them you know low to medium dose and see how that works i've already done this for sports injuries nsaids are better than other painkillers because they decrease inflammation one of the main mechanisms the body uses to heal itself is inflammation so that's the cons the issue of that when you look at all the studies that compare nsaids to placebo uh roughly about two-thirds of them actually show a benefit above placebo so they do work for pain control but not in everybody and when you compare them to other agents like acetaminophen you it's hard to find any of any evidence that they are better than just using plain acetaminophen or acetaminophen plus a narcotic uh and so this is the the most recent information and this is just a quote there was growing support for using paracetamol also known as the cinnamon in some countries including united states of america thank goodness we all do what they do in the united states of america as first line treatment for musculoskeletal sprains and strains because paracetamol may be just as effective yet will not increase bleeding into the injury site or potentially impair healing so that's the the thought process of as of today just for fun talking about a little bit about pain and sports there is a a really really good review in the bmj in the last little while on sports drinks this is an embarrassment for us as a society how little we know about these things and how much we use them it's called the truth about sports drinks and it was published in july 2012 i'm not going to go over in detail but it's a really really interesting read about the lack of value of sports drinks this is this is the some of the commentary there is a striking lack of evidence to support the vast majority of sport related products that make claims related to enhanced performance or recovery including drinks supplements and footwear how about this one i bet had you heard that you should before exercise you should drink water have you ever heard that one yeah if anything it makes things worse so it's a really cool myth oops so the best evidence when you look at it this is a meta-analysis of data from cyclists and time trials included that relying on thirst to gauge the need for fluid replacement was the best strategy and in fact what they found was that people who pre-hydrated had slower times and the only i'm not sure if it's true why guess why they thought that was the case they were heavier but what it did was show the best available elements is certainly not definitive is that you don't get an advantage from doing that and so that's probably the best use of sports drinks that you can think of i from a from a perspective and i think some of the key things there's a lot of concern about drinking too much water and there's a suggestion again not definitive there have been 16 recorded deaths and 600 people taking critically ill during competitive marathon running and it's primarily due to a drop in sodium and they think that it's not the fact that they are overly active it's that they've overly hydrated themselves and that's the concern so the big even though what five years so ago the recommendation was to pre-drink and all that sort of stuff the time trial stuff doesn't show it and there is the concern of doing that even with sports drinks there's no evidence that sports drinks reduce the chance of that from going on and i just want to spend a little bit of time talking about neuropathic pain this is a a very very difficult thing to treat we have a variety of medications that we use for neuropathic pain adele has talked about some of the tricyclic antidepressants there is a product called gabapentin which is out there what i thought i would share with you is most of the drugs that are being used for neuropathic pain do have some evidence of benefit is that not in your slide set i i can add it later on or you can just kind of i'm going to spend a few minutes just talking about it there's just some key messages that you can take from this is does gabapentin work there have been many clinical trials that have looked at it what gabapentin shows and by the way if you don't want to write it all down write the website because it's got all the information that we did i didn't do it but the group that i used to work with the therapeutic initiative put together a letter on gabapentin how effective is it for neuropathic pain well it appears that gabapentin reduces neuropathic pain by about one point on a 10 point scale and benefits about 15 percent of carefully selected patients so roughly one in six to one in eight people who you try gabapentin in one to in six to eight will get a clinically important benefit over and above giving placebo but a similar proportion of patients will get harm most of the trials show that the benefit can be achieved within a few days there is a huge practice right now that you push the doses of these medications that is just a bad friggin idea there is no evidence you need to push these medications in high doses and a lot of people just do not tolerate them so is there a role for gabapentin yeah it's like many of the other anti-seizure medications that have got evidence of benefit for for neuropathic pain like the antidepressants but when you use these agents you're only going to get about one in six to one in eight people will get a clinically important relief an equal number will get side effects they may not be the same people but boy oh boy you can stone people out with some of these medications they just they just don't do well on them because they get put on big doses on a long period of time and so on yes yeah so so so yeah absolutely and it's like it's like it's a painkiller it it i'm not saying it's like narcotics it's not like a narcotic but it there is a sedative effect and associated with it so i actually don't have a problem with using these agents or trying them especially if you've got neuropathic pain that there's no other thing because it's that's again a miserable thing to try so but what do you do you use some really common sense you start with a little bit you try it for a couple of days and if you get zero response from a little dose you're probably not going to get much more if you use a big dose but you might go up a next step to maybe double the dose see what happens and then if you get no response you stop and certainly if you get side effects you back way off when you start i think it's reasonable yeah yeah it would be interesting to know what she started on they some of the some of these people some people some clinicians recommend you know you should go at least to 1800 maybe you know even more than that and that's that's something that sedates a moose let alone anything else but not everybody some people tolerate it fine that's the weird that's the lovely thing about medicine and it's why we actually have jobs like if if if all the stuff worked really well equally and everybody i don't know what the hell we do we just say yeah works you do it but it's not like that so that i put up gabapentin there is an example but you can replace that with ametriptyline you can replace it with any of the medications that are used for chronic pain you get roughly speaking one in 10 and it actually comes down in a very similar fashion when we'll talk about migraine okay so any questions about sort of the use of pain medications for acute pain i'm going to now going to talk about uh drugs for headaches very similar principles but i'm just going to give you a little bit some of the evidence that we have available for headaches because there's some neat stuff for chronic that i think you'll find interesting do you guys need to take a break or you want to take a break at lunch i will get you out of here by 4 30. it just won't it might be 4 29. as we go along do you need to take a break or should we just go right till noon you want to take a break no most of you just i've lost the will to live and uh yeah whether or not i get up now is immaterial i've just yeah okay by the way this is all being recorded and i think that's going to be made available at some point we haven't even gotten it yet but at some point so all the rude comments that i make are edited out so it makes it really short talks no uh okay so drugs for headaches what are we gonna do with this first of all and this is important to realize we have a lot of drugs that cause headaches we have these drugs and what's really interesting amitriptyline is a drug used for migraine prevention but there is evidence that it causes headaches so we have a whole bunch of medications that can potentially cause headaches either from use or when we withdraw from them and so i would imagine knowing what you guys typically see you see a lot of people with chronic migraine chronic headaches and all that sort of stuff i'm not going to try to give you you know the treatment of all that takes hours and hours to go i'm just going to try and give you some common sense principles and approaches realizing that any new drug that you started if they didn't have a headache before now they do maybe it was the drug and withdrawal from a number of medications can worsen headaches now sometimes you just have to put up with it as you're trying to get people off of it medications you know the but that's just the way it goes so how effective are medications for headache for just your basic tension headache nsaids acetaminophen i'm not aware of any difference between them they work uh but let's look at the evidence for for migraine aspirin how many of you would this with a show of hands would take aspirin for a headache how many of you would not just with why not it doesn't help okay so good that's great doesn't help you does it bother your stomach yeah so these are all really good reasons however aspen is still a very useful agent to use and uh so migraine headache will be reduced from moderate or severe to no pain by two hours in about 25 percent of people who taking a single dose of a thousand milligrams of aspirin compared with about 10 percent uh migraine headache will be reduced from moderate or severe to no worse than mild pain by two hours and roughly 50 percent of people taking a single dose of aspirin compared with approximately 33 of people taking placebo that's very similar to what we talked about with acetaminophen very similar to what you would see with a number of other medications and some of those other medications are have you heard of drugs like imitrex or sumatriptan they were the apparently when they came on the market they were god's gift to migraine sufferers well sure they work but there's no evidence they're better than some of the other things it's nice to have alternatives because not everybody responds but this was an interesting trial in 2004 where they took asa versus sumatriptan versus ibuprofen versus placebo for acute migraine and i love these trials because it gives you a whole bunch of useful information it tells you what happens if i was to do nothing which is the placebo roughly there's a little bit of additional placebo effect in pain and then it compares these agents so it compares aspirin to immatrix to ibuprofen all in reasonable doses and this is what it showed this is the percent of patients with reduction in headaches severity from severe or moderate to mild to no pain at two hours so that's the white and these are the people who are pain free and you can see about a 20 to 30 percent absolute benefit using a medication over placebo when you're talking about being pain-free what is that about a 20 maybe a 15 to 20 absolute difference but what you can see there's not a heck of a lot of choice between aspirin ibuprofen or immatrix adverse events they didn't do any statistics on this but so i don't think you can really tease anything out of there other than if you're on placebo you get side effects if you're on an n said you get side effects most of the time when with a single dose like this it has nothing to do with the drug it's just stuff that happens remember i was mentioning to you using uh combination products well there's a thing called excedrin which is a combination of aspirin acetaminophen with caffeine if i as a first line recommended treatment that's what i'd be doing it's awesome there we go do you need any more proof than the person what's your name melissa says it's awesome we should we should do an a commercial one out of one naturopathic doctors recommend excedrin it's awesome i love it uh so how awesome is it well it works in you and this is the difference between placebo right there and giving those three products together and again it's about a 20 what is that 20 40 about an er what's that 40 absolute difference so there you go you could probably get about a 40 if you use aspirin and acetaminophen and uh caffeine together how effective are products like imitrex and i'll get to the side effects of them in a minute just so you know about those so there are hundreds of studies of these products there is sumatra 10 zomatriptan narrow trip 10 riser trip and electric and blah blah blah blah blah blah i'm not aware of any evidence that says one is better than another but how effective are you this is response at two hours this is pain free at two hours you get about sixty percent of people being paying for uh sorry or having a response at two hours compared to about twenty to thirty percent of people on placebo and as you can see there is very little difference between 25 50 and 100 of sumatra 10. that goes back to my whole premise that when new drugs come on the market they are usually overdosed when this product first came on the market it was 100 milligram tablet you can see 25 milligrams there's really not much to choose between them so you could use a quarter and get almost exactly the same effect this is the recurrence of the headache this is one thing that's somewhat unique to these products is that you do get in this case somewhere around 30 percent of patients will get a recurrence of the headache in two to 24 hours now how much that is that about placebo i think it was about 10 with placebo so about one in five people roughly speaking i think will get recurrence of their headache and that's somewhat unique it's not purely unique to these drugs but they seem to be more prone to this recurrence of headache within two to 24 hours what do you worry about with side effects most people tolerate them but you'll have people complaining of tingling parenthesis warm sensations in the head you can get rarer central nervous system effects and so on and so forth some of these are certainly dose-related and so on you can get chest related pain and people feel like it's a like a heart attack type pain but it's not a heart attack to the best of my understanding even though they've had chest pain i'd have to go back and look at to say there's never been a case of a cardiac event i'm not sure if that's true but when you look at it it doesn't appear to be necessarily cardiac of origin nonetheless there are side effects associated with this just like there are side effects associated with any medication there are a number of ways of giving these agents oral nasal and subcutaneous and the reason i'm going over this medication is because i've already talked so i'm blue in the face about acetaminophen and nsaids and so on but there's a variety of different dosage forms how do you decide between these well if they're vomiting oral is probably not a good route you can use nasal spray when it first came on the market it was subcutaneous but i don't know if anybody really needs to give it subcutaneous i don't know certainly no evidence that works better than oral we also have dihydrogen this is way outside i think your scope of practice or your where you should be practicing but it's just to show you there's another product called dhe or though do you guys have you seen it used or do you use it anyway it's an older medication it can be used you get more nausea but less chest pain than triptan is probably equally effective so here's my approach for migraines and it's not just my approach this is taken out of the guidelines based on the best available evidences for mild migraine if there is such a thing nsaids acetaminophen and caffeine plus a minus metaclopramide when do you add in metaclopramide only if they have a real problem with nausea it's actually being shown that nsaids acetaminophen reduce nausea as well probably because they get rid of some of the pain if no effect in an hour you can use tryptan and this used to be a big big no-no for migraines is that people would just shy away like mad from narcotics which i never ever understood because what would i rather have would i rather have a really painful headache and not sleep or a real painful headache and sleep so if it was me and i had a really bad migraine that was not treated with this i would just want lots of narcotics and then wake up tomorrow morning that would be me and so there is much less less reticent especially if it's a definite migraine if if you have a person who comes in it's their first they've never had a headache like this ever before they have all sorts of other symptoms you're not going to probably use narcotics because you don't you don't want to confuse the whole picture but if it's definitely a migraine and it's just a bad migraine and nothing else works narcotics now realizing i know you guys can't prescribe those but it's a change in the guidelines in that they're more likely to use narcotics why because it's humane because narcotics is so effective for pain control so what do we do for prevention yes yeah so the amount of coating that's in the over-the-counter products is eight milligrams it's probably not enough to really make much of a difference so i don't bother but if you took two or three of them now you're getting enough codeine for the people who will actually metabolize it into morphine because not everybody does so if you use three of them you get a pretty good dose of acetaminophen a pretty good dose of or ibuprofen and then you're getting probably enough narcotic to help but i you know all i can tell you is it's got eight milligrams and t3s are about 30. you like t3s oxycodone is best yeah we got a big drug user here no i'm sure yeah yeah how's that how's that uh iv heroin going pretty good now yeah that's the next step phase three so a lot of patients you'll see have a problem with chronic migraines what i would hope that you are aware of is the evidence for when to use and how effective prophylaxis is so here's a candidate for prophylaxis it the if the patient wants something that's the person who is a candidate now if you look at the guidelines they say recurring migraines frequent headaches which significantly inferior interfere with daily routines so but it really is ultimately patient preference if they're having migraines every month or two and they're sick to death of it i think it's reasonable to try something that prevents it and i'll talk about that as we go along so what's the benefit there is really solid good evidence of the benefit of using preventative medications and other things and i'll show you what those are for prophylaxis office visits if you use preventative stuff fifty percent reduction in office visits eighty percent reduction in emergency room visits reduction in evaluations for things a reduction in use of medications for acute migraines all sorts of stuff so how do we prevent stuff well you guys i would imagine are better at this and know more about this than i do but you try to avoid trigger factors if it's oral contraceptives the principles are that you use the very lowest effective preventative dose that you can find it may take two to three months to see if it's having an effect and it's not because it necessarily takes the drug that long to work but why do you think it might take that long to figure out if there's an effect pardon yeah the frequency the migraine may be only once every couple of months so then it's really tricky to figure out uh you discuss the expectations and maybe even have a formal management plan maybe even a diary it doesn't have to be anything fancy but just so that you know so that when they come in they have a reasonable idea of what it was like what's happened so this is a list and this is an old list from about eight nine years ago this is a list of agents that have demonstrated efficacy superior to placebo and randomized trials we have stuff that works beta blockers calcium channel blockers nsaids um antidepressants ssris valpro casted riboflavin magnesium fever few histamine lysine problems there's a lot of stuff to try which one do you try i don't have a clue if it was me what would i try i'm going to try puppy beta blocker but really really really really low dose and i'm also not i don't run marathons if i ran marathons i wouldn't because i don't think you get your heart rate up enough but i think i might try a really low dose and these doses here by the way are not the recommended doses these are just doses that have been used for instance natalol is a really good example or even for pranalol five milligrams of propranolol has a has effect so i don't know what dose to use but you take the lowest dose available and maybe give them a quarter of a pill and say you know what we're just going to try this a little bit yeah well what do you think well let me show you the benefit and then you could so so part of the problem is they may be in that medication-induced headache process where so so that's so all bets are off with that but if they if they're having daily headaches um well let me show you the benefit and then you can then you put it in the comments so here's the bottom line on prevention and for most of those medications and things that i showed you this is what you're when i say there's a benefit this is typically what it is when we're talking about prevention about 50 there's a 50 reduction in headache severity frequency duration usually assessed at three months that's the that's how they're defining it at um as a benefit so a 50 reduction in headache severity so across all high quality trials 24 will have a response on placebo so that's why and i don't mean this in a derogatory way it's why what some of what you do works is it just got better on its own but all those products that i showed you you get about another twenty percent maybe twenty five percent absolute benefit in getting people to a 50 reduction in headache severity so whatever you try you have a 50 50 chance of it working but only one in five got the benefit because of the therapy so in my opinion the person who's got chronic migraines and nothing seems to work i'd let up to say are you interested in trying one of these things because we we got 50 50 chance that if we give you something really low doses and side effects are unacceptable i'm going to try a low dose and let's see if it goes away and then guess what you do within six to eight months yeah you re-evaluate because i don't know if you know the natural history of migraines as you get older they go away not in everybody but in that's the general history that you see so your question was would i use it i ask you i would if i had chronic headaches where i was kind of constantly having to take something all the time on a regular basis and there was no other you know it wasn't because i had something very bad going on in there i would i unless you're a masochist or narcissist whatever it is whichever way it is i can always forget those words uh whichever one of those unless you're inflicting a headache on someone versus the other well what i don't know what do you got what do you guys see in practice you must see a lot of this right what do you guys do you sit there does it say nothing oh it seems to help them yeah i mean all the we do all of those things absolutely yeah yeah so any question that's a real quick run through migraines but we again the treatment is like pain control and then prevention