Category: Diseases and Disorders

Migraine Abortive Treatment Guidelines and Prevention of Migraine Headache

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A migraine is a severe headache, often accompanied by nausea, vomiting, and light sensitivity. These headaches may last from four hours to several days. The American Migraine Foundation estimates that migraines occur in 1 billion people worldwide. Migraine affects adult women about 3.25 more often than men.

 1

 

 This is likely the result of hormone fluctuations occurring in females. The fact that prepubertal children have a migraine incidence of 3-10% regardless of gender also supports the theory that hormones play a role.

 2

 

The incidence of migraines remains relatively equal in boys and girls until the age of nine. After nine, more girls experience these headaches.

 3

 

It is known that estrogen is able to cross the blood-brain-barrier freely. Obese women have a higher risk of developing migraines. This is thought to be due to increased estrogen production in the adipose tissue.

 4  5

Migraine headache ranks seventh globally for years lived with disability.

 6

Migraine Aura Triggers

In fifteen to thirty percent of migraine sufferers, an aura precedes the headache pain.

 

This is most commonly visual but may be a disturbance of speech or motor function as well. This phase generally lasts less than sixty minutes.

 

I am fortunate to have only had a few migraines during my lifetime. My headaches always begin with visual problems, and I am unable to perform simple tasks such as opening a combination lock. I also have trouble speaking and have word-finding difficulties. The symptoms I suffer mimic a stroke.

 

What are the triggers of migraine headaches?

Medication Overuse Headache

Medication overuse headache (MOH) occurs when analgesics, triptans, or ergotamine agents are overused chronically. It is essential to take medications only as prescribed by your physician. There is an increased risk of MOH with opiates, Fiorinal, and analgesic medications containing barbiturates.

 7

Medication less likely to cause MOH are hydroxyzine, metoclopramide and low-dose non-steroidal anti-inflammatory drugs such as ibuprofen and naproxen.

 8

Medications That May Trigger a Migraine

Several drugs have the ability to trigger a migraine. These include oral contraceptives, reserpine, nitroglycerin, cocaine, nifedipine, and hydralazine.

 

 If you suffer from migraines and are taking any of these, ask your physician for a substitute. 

 

If you are using cocaine, either stop on your own or get treatment. Cocaine is very addictive and extremely dangerous.

Diet

Many foods are known to precipitate migraine headaches. Some of these include chocolate (I know, this is sad), processed meats, aged cheeses, onions, oranges, tomatoes, and some dairy products. Red wine and champagne consumption can also lead to migraines.

 

Caffeine is a double-edged sword. It can help with migraine treatment, but caffeine withdrawal can cause headaches in some individuals. For this reason, it is recommended that frequent migraine sufferers stop ingesting caffeine for a two to three month period to determine if headache frequency declines.

 9

Individuals who consume large amounts of caffeine should slowly taper off the drug to decrease the chance of precipitating a withdrawal headache.

 

It is also important to be aware of additives and food preservatives. Substances such as aspartame and MSG can trigger a headache. Whole foods are always the safest option.

 

Environment

Cigarette smoke, perfume, weather changes, loud noises, and bright or flickering lights can cause a migraine. A change in altitude and extreme heat or cold are also culprits. 


Getting too little or too much sleep can be a trigger. If possible, sleep at the same time each night for the same amount of time. Try to eat at regular intervals. Skipping meals has been shown to trigger migraines in some individuals.

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Other Migraine Triggers

People with psychiatric disorders are more prone to migraines. Stress and menses also increase migraine risk.

Treatment of Migraine Headaches

It is a pretty safe bet that either you or someone you know suffers from migraine headaches. You are most likely reading this because you want to know how to make them stop! 


I am going to go over abortive treatment as well as prophylactic (preventative) treatment of migraines. My goal is to present the medications with the most evidence to support their use. 


Please remember that different people respond to various therapies. What works for others may not work for you. I am going to present a list of the treatments that are most likely to be effective.

Biofeedback for Migraines

During my research on migraines, I came across an article that discussed the use of biofeedback as prophylaxis for pediatric migraine headaches. Even though I am a pharmacist, I will always recommend non-drug treatments for patients if they are safe and effective. 

 

There is not a single medication that does not possess side effects.

 

Biofeedback is where patients learn to control automatic bodily functions through the use of feedback such as temperature or muscle tension. When properly trained, the patient can control the temperature of their hands, for example, without the use of equipment.

 

When we are under stress, the blood vessels in our hands become smaller. With less blood flowing, the temperature of our hands decreases. By learning to relax using biofeedback, it is possible to lower the stress level, which increases the size of the blood vessels leading to warmer hands.

 

But does this work for migraines?

 

Nesoriuc and Martin published a meta-analysis on the effectiveness of biofeedback for migraine in 2007. They reviewed 55 studies, which included 2229 migraine patients. 

 

The conclusion was that biofeedback significantly and substantially decreases the pain and psychological symptoms after only eleven sessions. This led to the recommendation that biofeedback can be used as an evidence-based behavioral treatment option for migraine headache prevention.

10

A meta-analysis looking at biofeedback as prophylaxis for pediatric migraine was conducted in 2016. The researchers concluded that biofeedback is most likely effective, especially when combined with relaxation therapy. Since the number of studies was small, and they had methodologic issues during the meta-analysis, their recommendation is to continue research on this topic.

 11

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Migraine Abortive Treatments According to the Guidelines

When you get a migraine, it can be disabling. Light, noise, and even movement can make the pain worse. 


The first thing most people reach for is Excedrin migraine or ibuprofen. Excedrin migraine is acetaminophen (Tylenol) and caffeine. If this works for you great, but remember, if you get migraines often, you should avoid caffeine. 


The over-the-counter medications with the best data to support use in the treatment of a migraine headache are aspirin, ibuprofen, and naproxen sodium. If these are ineffective, see your doctor.


What are the first-line treatments for migraines?

Triptan Drugs for Migraines

Triptans are first-line for migraine pain relief. There are several drugs in this class. Imitrex (sumatriptan) is the most common. Imitrex comes in a variety of dosage forms, including nasal spray, tablets, transdermal patches, and subcutaneous injection. The injection is the fastest acting and also the most effective. Remember, nausea often occurs with a migraine, so taking anything by mouth can lead to vomiting. 

 

The triptans work by making the blood vessels in the head smaller. These drugs should NOT be used in hemiplegic or basilar migraines.

 

There seems to be a difference in the effectiveness of the triptans in individual patients. My advice is to see what your insurance company covers and start with that. If it doesn’t help, try another agent. The most significant difference in the individual triptans is the dosage forms available and the onset and duration of action.

 

Triptans available are listed below:

 

  • Sumatriptan (Imitrex) – Injectable is ultra-fast acting and the most effective. Also available in tablets, nasal spray.
  • Rizatriptan (Maxalt) – Available in disintegrating tablets and regular tablets.
  • Zolmitriptan (Zomig) – Tablets, disintegrating tablets, and nasal spray
  • Naratriptan (Amerge)- Slow acting/ long-lasting
  • Almotriptan (Axert) – Tablets only.
  • Eletriptan (Relpax) – Tablets only
  • Frovatriptan (Frova): Longest acting triptan

Dihydroergotamine (Nasal Spray) for Migraines

Dihydroergotamine is available as a nasal spray (Migranol), as well as an injection that can be given intravenously, subcutaneously, or intramuscularly.

It works by constricting blood vessels. Like triptans, this medication should not be used in hemiplegic or basilar migraine.

Only the nasal spray received a level A recommendation from the American Headache Society (AHS).


The drugs in this class were the treatment of choice before the triptans were available. Ergot alkaloids such as dihydroergotamine should not be given along with protease inhibitors, macrolide antibiotics, or antifungal agents.

Ask your doctor or pharmacist if you have any questions about this.


Ergot alkaloids have many side effects, but the most common is nausea and vomiting. The nasal spray is the preferred route of administration due to less nausea.

Other Level A Recommendations for Aborting Migraines

Acetaminophen (Tylenol): Good choice for pain, especially in older individuals or those with kidney problems.

 

NSAIDs: Aspirin, ibuprofen, and naproxen sodium have the most evidence.

 

Opiates: May be useful but not recommended for chronic use. Side effects and addiction potential may outweigh benefits.

 

Sumatriptan/naproxen (Treximet)-A combination product promoted by the drug company. 

 

Acetaminophen/Aspirin/Caffeine (Extra strength Excedrin)-Works very well for some but careful with caffeine.

Migraine Prevention Treatments According to Guidelines

If you experience migraine headaches often or are having to miss work on a regular basis, you may wish to take something to help prevent the headaches.

Which therapies are recommended?

Aniticonvulsants

Depakote for Migraine Prevention

Divalproex (Depakote) has substantial evidence to support its use in the prevention of migraine headaches. A Cochrane review published in 2013 found patients taking Depakote were twice as likely to decrease migraine frequency by 50% or more than those taking placebo.

 12

 

Depakote does have adverse effects and risks associated with its use. It can cause congenital disabilities and should be used with caution in women of childbearing age. It also may cause weight gain, nausea, hair loss, and dizziness. Depakote has also been associated with liver failure, but this is uncommon. 

Topamax for Migraines

Topamax also has a Cochrane review that supports its use in migraine prevention.

 

This review looked at seventeen trials and found topiramate to be two times more likely to decrease the frequency of migraines by 50% or more when compared to placebo.

 13

 

Topamax can decrease appetite and commonly causes a burning or prickling sensation in the feet, arms, legs, and hands. It may also cause nausea, difficulty with memory and concentration, kidney stones, and word-finding problems.

 

 

Other Level A Recommendations to Prevent Migraines

For women who suffer from menstrually associated migraines (MAM), frovatriptan (Frova) should be offered for short-term relief.

 14

 

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Treatment of Nausea Occurring with Migraine

More than two-thirds of patients who experience migraine headaches vomit during their attack.

 15  16

Many drugs used for nausea and vomiting can also be used to treat migraines. Below is a list of the most popular agents that fit this category.

Promethazine for Migraines

Promethazine is a drug used primarily for nausea and vomiting. It can also be effective in the treatment of migraine and received a level B recommendation (probably effective) from the AHS.

 17

 

This medication is available in multiple dosage forms such as tablets, injection, syrup, and suppositories. This makes promethazine useful during a migraine accompanied by nausea and vomiting. 

 

Promethazine has the potential to be abused due to its sedative effects and its ability to cause delirium. It is also known to increase euphoria when combined with opiates.

The recreational drug “purple drank” is a mixture of promethazine with codeine, hard candy, and carbonated soft drinks.

 

This mixture is popular among the hip-hop culture.

 

Promethazine should not be used in patients with asthma.

It can cause many side effects such as nausea and vomiting, dry mouth, problems breathing, dizziness, and sedation.

Chlorpromazine for Migraines

Chlorpromazine (Thorazine) is also a level B recommendation, according to the AHS. This medication is a phenothiazine that blocks dopamine receptors. This is how it works as an antipsychotic agent.

 

Chlorpromazine also possesses anti-nausea effects.

A study conducted in 2002 found chlorpromazine to be significantly better than a placebo in treating migraine headaches in the emergency room.

 18

 

 Chlorpromazine does cause a high level of sedation and postural hypotension. It is a highly anticholinergic drug leading to dry mouth, blurred vision, constipation, and confusion. It is available as a tablet and injectable form.

 

Droperidol for Migraines

Droperidol is also probably effective in the treatment of migraines, according to the AHS.

 

I have spent countless hours working in the hospital setting, and I definitely received complaints when droperidol was on back-order.

 

It is undoubtedly one of the favorite agents used for migraine at my institution. 

 

Droperidol can have some pretty severe cardiac side effects. It may also cause anxiety, restlessness, and a dysphoric mood. 

 

This drug is normally used as a pre-anesthetic agent for sedation before surgery. Droperidol has a very short duration of action. 

 

It is only available in an injectable form.

Metoclopramide for Migraines

Metoclopramide (Reglan) is also classified as probably effective by the AHS. It is available as a tablet and as an injectable form. Reglan should not be used in patients with epilepsy. Headaches may be caused by Reglan in some individuals. Drowsiness, nausea, vomiting, and movement disorders may also occur with its use.

Alternative Migraine Treatments

There are migraine treatments available that utilize dietary supplements and other medications such as Botox.  I have included some of the most popular and effective therapies below.

Botox Shots for Migraines

Botulinum toxin type A (BTX-A) was approved for the treatment of adult chronic migraine headaches in 2010.

 

Most of the data which led to this approval was obtained from two randomized, placebo-controlled, double-blind studies also published in 2010.

 19   20

BTX-A is administered intramuscularly at a dose of 155 units once every twelve weeks. Each dose should be equally divided and administered to thirty-one specific muscle regions of the head and neck, as shown below.

 

 

 

 

 

The images above were taken from the Botox package insert by Allergan, 2019

According to the American Academy of Neurology (AAN), BTX-A is safe and effective for chronic migraines and is probably effective for improving health-related quality of life (QOL) for these patients. They recommend offering BTX-A to chronic migraine sufferers to increase the number of headache-free days and improve QOL. 

 

Chronic migraine is defined as fifteen or more headaches per month for at least three months. These headaches must last four hours or more.

The AAN recommends against the use of BTX-A for episodic migraine and considers it ineffective for this population.

 21

 

 An updated Cochrane systematic review was published in the British Medical Journal in 2019. This review included twenty-eight trials, which included 4190 subjects. 

 

I prefer to cite Cochrane reviews whenever possible as they are reliable, and their evidence has the most impact on the scientific community.

 

They also update their studies when new information becomes available, as is evidenced in this subject.

 

Of the twenty-eight trials identified, twenty-three compared BTX-A with placebo injections. Three of the trials compared BTX-A with other migraine prophylactic drugs.

 

The studies comparing BTX-A to placebo included 23 trials with 3912 subjects. The analysis showed a reduction of 3.1 days of migraine occurrence per month in the BTX-A group.

 

In an episodic migraine subgroup of 418 subjects, no difference was found between the two groups.

 

It should be noted that BTX-A is very expensive compared to other treatment options.

 

It should be reserved for those with chronic migraine headaches who do not respond or cannot tolerate other therapies.

Butterbur for Migraine Headaches

Petasites hybidus, or butterbur, is a shrub that grows in wet, marshy soil. The large leaves have traditionally been used to wrap butter during warm weather to prevent melting.

This plant has been used to treat fever, cough, asthma, and wounds of the skin.

It is important to note that unprocessed butterbur contains pyrrolizidine alkaloids (uPA). These may be harmful to the liver if ingested over a prolonged period.

Butterbur, which has been processed to remove uPA is safe to consume.

 22

 

There have been studies comparing butterbur to placebo.

In one study conducted in 2000, sixty men and women who suffered from a least three migraines per month were given either 50 mg butterbur extract or placebo twice daily for three months. Seventy-five percent of the butterbur group reported improvement in the number of attacks and total number of days with migraine pain, compared to only twenty-five percent of the placebo group.

 23

Another study administered either 50 mg butterbur extract twice daily, 75 mg butterbur extract twice daily, or placebo twice daily to 202 people with migraines for three months. Patients in all three groups saw improvement in their headaches, but the 75mg butterbur group saw significant improvement as compared to the placebo group.

 24

 

Magnesium and Riboflavin for Migraines

A meta-analysis published in 2014 compared IV magnesium with placebo in emergency room patients presenting with migraines.

 

Subjects received either IV magnesium, a dopamine antagonist, or a placebo.

More patients experienced pain relief in the magnesium group than in the placebo group, but it was not statistically significant. 

 

This study also discovered magnesium works better in patients who have migraine with aura. There was no difference in effectiveness between magnesium and placebo in patients with migraine without aura.

 

It was also discovered that the magnesium-metoclopramide combination led to more pain relief than the placebo-metoclopramide combination.

 25

 

Riboflavin has been found to be effective at reducing the number of migraines when taken at a dosage of 400 mg per day.

 

In a study of fifty-five patients, 400 mg of riboflavin daily was found to be superior to placebo at reducing both the number of headache days and the frequency of migraines.

 26

 The most common side effects of riboflavin are diarrhea and increased urination. 

 

Both magnesium and riboflavin can be found in many foods:

Feverfew and Ginger for Migraines

Feverfew (Tanacetum parthenium) is a plant with flowers resembling daisies that grows wild throughout the world. This plant has previously been used for its anti-inflammatory properties and pain related to menses in women. 

Tanacetum has been used to prevent migraine headaches. The flowers contain a compound known as parthenolide, which is thought to decrease the incidence of migraines utilizing multiple mechanisms of action.

Inhibition of cyclooxygenase-2, tumor nucrosis factor-alpha, interlukin-1, 

 27

and serotonin

 28

are all thought to be involved.

A systematic review of the literature regarding feverfew and migraine was published in the Journal of Dietary Supplements in 2009.

 29

Some interesting information was gleaned from this study. It is possible that other compounds contained in the feverfew leaves assist in parthenolide’s mechanism of action. 

 

One of the studies found no benefit of an alcohol extract of parthenolide, while two other studies using dried leaves found a statistically significant decrease in migraine severity and frequency.

 

These studies found feverfew to be safe with no difference in adverse effects as compared to placebo.

 

It is important to note that feverfew is a supplement which is thought to prevent migraine, not treat the actual headache. For this reason, patients will be taking the supplement over an extended period.

 

More studies are needed to assess the long-term safety and recommended dosage of this supplement.

 

Can ginger fight a migraine headache?

 

Ginger is a common spice used in cooking. It is also used to cleanse the palate in between the consumption of various types of sushi.  Ginger is native to southeastern Asia.

 

This plant has been used for many medical purposes, including treatment of motion sickness, generalized pain, vertigo, arthritis pain, and dyspepsia.

 

One study conducted in 2005 found Gelstat (an OTC drug containing ginger extract) completely alleviated migraine pain in forty-eight percent of patients within two hours.

 

Thirty-four percent achieved partial relief during the same period.

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In a study published in May of 2013, Maghbooli et al. compared ginger to sumatriptan in the treatment of migraine headaches.

 

One-hundred patients were selected to either receive ginger or sumatriptan if a headache occurred. 

 

Twenty-two percent of the sumatriptan group and twenty percent of the ginger group had a severe headache during the study and were treated. 

 

Seventy percent of the sumatriptan group and sixty-four percent of the ginger group had their headache pain decrease by at least ninety percent two hours following drug administration.

 

There was not a significant difference between the two treatments regarding migraine pain relief.

 

The only side effect reported by the ginger group was dyspepsia. Alternatively, the sumatriptan group reported dizziness, dyspepsia, vertigo, and sedation.

 

Although this study had a limited number of subjects, it shows promise in ginger’s ability to fight migraine headache pain.

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A dosage recommendation of 500 mg ginger taken at headache onset and repeated every four hours up to 2 grams daily for three to four days has been recommended by Mustafa and Srivastava.

 32

 

Try Turmeric with Ginger for your Migraine

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Migraine headaches are a common health problem today. They lead to decreased productivity, increased health care costs, and a lower quality of life. 

 

There are many treatments for this disorder. Choosing the right therapy depends on several factors. Patients who have nausea and vomiting occurring with their headaches may benefit from an agent that is available as a non-oral dosage form. 

 

Elderly patients or those with kidney disease should be careful with NSAIDs. These drugs can damage the kidneys, especially if taken over a long period.

 

Those who suffer from multiple monthly migraine attacks may want to consider preventive drug treatment. Again, there are many options to accomplish this, and they are patient-specific.

 

I suggest keeping a headache journal. Write down what you eat each day, your activity level, exposure to smoke or strong odors, and hours of sleep as well as the level of stress. Try to find a pattern that leads to your headaches. It may be easier to avoid foods or other factors that cause your headaches than to use medications. 

 

Consider biofeedback. It does take an initial time commitment but may pay off in the future if you can learn to master it.

 

Other alternative therapies, such as vitamins and nutraceuticals, may also decrease headache frequency. It is possible to get some of these just by eating certain foods.

 

More studies should be done in the future regarding these agents in the treatment and prevention of migraine.

I have covered the medications with the most evidence in this post. There are many more second and third-line agents available as well.

 

At times it may be necessary to combine medications to get the desired effect.

 

If you have any questions regarding migraine headaches or any other topic, please feel free to send me a message. I am always happy to help whenever possible.

 

Michael Brown in Lab Coat with arms crossed

Michael J. Brown, RPh, BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.

Read Michael’s story here.

Feel free to send Michael a message using this link.

 

 
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Fibromyalgia Causes And Treatment With Guaifenesin, Amitriptyline, Kratom, Flexeril, And Others.

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Disclosure:  This post may contain affiliate links, meaning, at no additional cost to you, I may earn a commission if you click on, or make a purchase through a third-party link.

Fibromyalgia (FM) is a disorder affecting approximately 2% of the world’s population. FM is characterized by musculoskeletal pain occurring throughout the body. Patients with this condition may also suffer from:

 

  • Fatigue
  • Mood problems
  • Memory issues
  • Sleep disturbances
  • Headaches
  • Anxiety
  • Depression

  

FM is a chronic disorder with subjective symptoms making diagnosis difficult. At present, FM cannot be diagnosed based on objective data.

 

Fibromyalgia has previously been thought of as a diagnosis to use when symptoms did not fit any other condition. Some physicians are still unsure whether this is an actual disorder. Patients may become depressed or frustrated due to a lack of compassion from various caregivers. 

Previously, many physicians believed patients were using fibromyalgia as an excuse to obtain pain medication. We are now finding that changing one’s lifestyle may be more effective than drugs. 

Suspected Causes of Fibromyalgia

The exact cause of fibromyalgia remains a mystery. It is most likely due to several factors. We believe some of these include:

  • Genetics: Fibromyalgia is more prevalent in people who have genetic relatives with the disorder. This leads us to think it may be due, at least partially, to a genetic mutation.
  • Trauma: This may be emotional or physical. We know that in some cases, fibromyalgia occurs after the person sustains an injury or experiences emotional stress. Victims of child abuse have a higher incidence as do those with posttraumatic stress disorder (PTSD). The brain may react differently to stress and pain in these individuals which may explain this link.
  • Mood disorders: Individuals with any mood disorder, including anxiety and depression, are more likely to suffer from fibromyalgia. 
  • Gender: Women are three times more likely to be diagnosed with fibromyalgia compared to men. 1This may be due to a difference in how women react to pain or society’s expectations of how women should respond to pain.
  • Sedentary lifestyle: People who don’t exercise are much more likely to suffer from fibromyalgia. Exercise is one of the main treatments.

There is some thought that FM may be the result of the body overreacting to pain signals. This could be due to an imbalance of neurotransmitters in the brain.

 Even weak signals may be perceived as pain if this is true.

The main obstacle in determining fibromyalgia’s cause is the fact that most people with this disorder also suffer from other conditions. 

Many have rheumatoid or osteoarthritis, migraine headaches, various mood disorders, and other maladies that cause pain. It is challenging to separate FM from these coexisting conditions.

A large number of the studies conducted on this subject have a small sample size, or patients are lost to follow up. More well-designed studies are needed to determine the causes of this debilitating condition.

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Cymbalta for Fibromyalgia

A meta-analysis was performed using data from the year 2000 until March of 2019.  The purpose of this analysis was to determine efficacy and proper dosage of Cymbalta (duloxetine) in the treatment of fibromyalgia. This included seven studies with 2642 fibromyalgia patients. The results showed duloxetine was more efficacious than a placebo for pain control in these patients. 

The standard mean difference between duloxetine and placebo was -0.26 or 26% better pain relief. 

There were more adverse effects suffered by the duloxetine group, and withdrawal effects were more significant in those receiving 120 mg/day. The study concluded duloxetine was a great choice for relief of pain in fibromyalgia patients

 2

A study published in June of 2019 compared duloxetine (Cymbalta) with pregabalin (Lyrica) in the treatment of fibromyalgia. 

All subjects were women with FM between 18-65 years of age. They were each assigned either duloxetine 30-60mg daily or pregabalin 75-150 mg daily for four weeks. 

The Widespread Pain Index (WPI) was used to measure pain severity. This scale quantifies body pain by asking patients if they have pain or tenderness in 19 body regions. The higher the score, the more widespread the pain. Duloxetine was significantly better in improving the WPI score with a mean difference of (-2.32) when compared with pregabalin.

The prevalence of nausea and the dropout rate was significantly higher in the Duloxetine group as compared to the pregabalin group.

 3

A Cochrane database review was published in 2018 titled “Serotonin and noradrenalin reuptake inhibitors (SNRIs) for fibromyalgia.” This was a comprehensive study focusing on the efficacy of SNRI’s on numerous FM symptoms.

This study concluded that only a minority of patients might benefit from treatment with duloxetine or milnacipran. Most patients will not gain relief from FM symptoms, or they will experience adverse effects leading to drug discontinuation. 

There is no evidence to support the use of other SNRIs such as venlafaxine or desvenlafaxine in the treatment of FM.

 4

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Lyrica and Neurontin for Fibromyalgia

There was a Cochrane review published on the effects of anticonvulsants on FM. Since the lead author received financial support from commercial sponsors, this review has been withdrawn from publication.  

 

This study was, however, listed as a reference in the European League Against Rheumatism (EULAR) revised recommendations for the management of fibromyalgia. 

 

Pregabalin is listed as a pharmacotherapy for severe pain and severe sleep problems. Neurontin (gabapentin) is not recommended in the treatment of FM, according to EULAR.

 

Amitriptyline for Fibromyalgia

There is evidence that amitriptyline can help with sleep, fatigue and pain in FM at low doses. Five reviews involving 919 subjects found those receiving amitriptyline were 60% more likely to acheive a 30% reduction in pain. A moderate improvement in sleep and a small effect on fatigue were also shown.

 5

Guaifenesin and fibromyalgia

Guaifenesin is an expectorant used primarily to loosen mucous in the airways. This helps the patient cough up the mucous and remove it from the body leading to more effective breathing. Guaifenesin is sold under the popular brand name Robitussin. It is also available under the brand name Mucinex as a 12-hour tablet formulation.

 

There is a protocol available on line that promotes the use of guaifenesin in the treatment of fibromyalgia. I do not see any harm in trying this method if you suffer from FM. Guaifenesin has few side effects. It is important to note that this protocol states that salicylates of any kind must be avoided for guaifenesin to be effective. This includes aspirin and all topical salicylate formulations. The protocol can be found at the link listed below:

 

http://www.fibromyalgiatreatment.com/the-guaifenesin-protocol.html

 

A study conducted in May of 2009 used a telephone survey of 632 women to gain insight into the subjective pain relief obtained by several agents in the treatment of FM. 

 

Of the women surveyed, 434 claimed to have FM while 198 denied having the condition. The women had an age range of 18-80 years. 

 

The results of this study showed that half of the FM group were taking antidepressant medication. Tri-cyclic antidepressants (TCA’s) had strong effectiveness while serotonin reuptake inhibitors (SSRIs) had only moderate effectiveness in treating FM. Few were taking SNRI’s at this time. 

 

Almost 30% of the FM sample were taking non-steroidal anti-inflammatory drugs (NSAIDS). 

 

I included this study because even though it was conducted in 2009, it showed that the most effective medications to treat FM according to the subjective reports of the patients were opiate narcotics and guaifenesin. The narcotics aren’t surprising, but guaifenesin is.

 6

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Kratom for Fibromyalgia

Kratom is a substance obtained from a tropical evergreen tree found in Southeast Asia. This substance has been used for centuries to improve stamina and increase the energy of workers in its native region.

Kratom is available as a supplement in the US. People utilize it to treat diarrhea, pain, and to decrease the symptoms of opiate withdrawal.

An anonymous national survey was conducted in 2016 in an attempt to discover the usage patterns of Kratom in the US. This survey included 8049 Kratom users.

It is known that Kratom is used as an alternative to opiates. Fibromyalgia had the lowest proportion of “significant improvement” responses in this survey. This is expected as opioids are not recommended as a treatment for FM

 7

Flexeril for Fibromyalgia

Cyclobenzaprine (Flexeril) is a muscle relaxant used for various musculoskeletal disorders.  

A systemic review of 312 patients taking cyclobenzaprine for FM found 85% suffered side effects and only 71% of the subjects were able to complete the studies.  

This review concluded sleep was slightly improved, but pain was not.  

Cyclobenzaprine can be used for severe sleep problems in FM

 8

Trazodone is an antidepressant used mostly for insomnia at the current time.  This medication was not mentioned in the EULAR revised recommendations for the management of fibromyalgia.  

If other sleep agents recommended fail, I would not be opposed to trialing trazodone. This drug is effective for sleep at low doses.  Getting the proper amount of sleep is very important.

Celexa and Fibromyalgia

Citalopram belongs to a class of drugs known as selective serotonin reuptake inhibitors (SSRIs). Seven systematic reviews were conducted looking at this drug class for the treatment of fibromyalgia. These medications may have a small effect on pain and fatigue but do not help with sleep. Since SNRI’s discussed above are more useful for FM, SSRIs are not recommended.

The EULAR revised recommendations for the management of fibromyalgia were published in 2017

 9

Michael Brown pictured with Final Thought written

The EULAR recommendations for the treatment of fibromyalgia maintain that prompt diagnosis and patient education are critical. The patient should be assessed for pain, level of function, and management should be geared towards improving the quality of life.

Non-pharmacological treatments should be initiated first. These include physical therapy with an emphasis on individualized exercise. Other therapies, such as acupuncture and hydrotherapy, may also be tried at this stage.

Psychological therapies should mainly consist of cognitive-behavioral therapy. If depression and anxiety are severe, psycho-pharmacological treatment can be utilized.

Recommendations for pharmacotherapy, according to EULAR, are as follows:

Drugs that should not be used:

  • Strong opioids
  • Sodium oxybate
  • Corticosteroids
  • Growth hormone

Drugs recommended for severe pain:

  • Duloxetine
  • Pregabalin
  • Tramadol

Drugs recommended for severe sleep problems:

  • Low dose amitriptyline
  • Cyclobenzaprine
  • Pregabalin

I have attempted to review the most up to date medication treatments for fibromyalgia in this post. I have included the recommendations from EULAR as well as information on Kratom, guaifenesin, and trazodone.

I do not recommend the use of Kratom at this time. I believe guaifenesin may have a benefit, and it has very few side effects. Trazodone is a good drug for insomnia at low doses, so it may be tried if other treatments fail.

After researching this subject, it seems that exercise, hypnosis, guided imagery, and other non-pharmacological treatments are the preferred treatment of fibromyalgia.

More research will surely be done on this subject, and hopefully we will obtain better treatments in the future.   

Thank you for reading my blog, and please contact me with questions.

Michael Brown in Lab Coat with arms crossed

Michael J. Brown, RPh, BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.

Read Michael’s story here.

Feel free to send Michael a message using this link.

 

 
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Several Vitamin D3 5000 IU Benefits And Why You Should Take This Supplement

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Do you need to take a vitamin D supplement?

Many of us are deficient in vitamin D. The only way to be sure is to have a blood test performed. The test used is the 25-hydroxy vitamin D test. Our hospital lab lists the normal blood level to be 30.0-100.0 ng/ml. The Vitamin D council lists the ideal level between 40-80 ng/ml. I recommend supplementation in patients who have a level less than 30 ng/ml.

 

What’s the big deal? I live where there isn’t much sun! Why do I need Vitamin D?

It turns out that vitamin D performs many important functions in our body. As more research is completed, we are finding this vitamin helps with physical and mental health.

Vitamin D is one of the four fat-soluble vitamins (A,D,E and K). This vitamin is not found in many foods but is added to milk, tofu, and orange juice. Shitake mushrooms are also a good source of vitamin D.

Our bodies synthesize vitamin D when the skin is exposed to ultraviolet light from the sun. If we aren’t getting enough sunlight and eating enough foods rich in vitamin D, we are likely deficient in this vitamin.

 The other way to get this vitamin is to take a supplement. All supplements are not created equal. The Sunshine Nutraceutical Vitamin D supplement is made in the USA in an FDA inspected facility. Our supplement contains 5,000 IU of vitamin D3 in a soft gel capsule.

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Being Deficient In Vitamin D Comes With A Cost. Here Are Several Problems You May Face:

Osteoporosis

Osteoporosis occurs when the body loses too much bone tissue or is unable to replace bone loss efficiently. This causes the bones to become weak and are more easily broken. People with this condition may break a bone simply by bumping into something or sneezing. 

The first sign that you have osteoporosis is usually when you break a bone. People with reduced bone density do not feel any different. The chances of a person with osteoporosis breaking a bone is 50% for women and 25% for men during their lifetime

 1

You have a higher risk of breaking a bone if you:

  • Are a smoker.
  • Have a low body weight.
  • Are female.
  • Have broken a bone previously.
  • Drink three or more alcoholic beverages daily.
  • Have gone through menopause.
  • Are over fifty years old.
  • Have low calcium and vitamin D intake 2

    The most important mineral in your bones is calcium. Vitamin D helps the bones absorb calcium. If you don’t get enough vitamin D, calcium cannot be absorbed for use by the bones. More calcium in the bones increases density which decreases the chance of a bone fracture

     3

    The incidence of broken bones increases during the winter months. Some researchers believe this is due to lower levels of vitamin D

     4

    A study published on August 1st, 2019 examined the effect of vitamin D levels on fractures in 287 elderly women with at least one previous bone fracture. This study concluded that vitamin D deficiency was associated with an increase in fracture severity as well as bone loss.

     5

General Anxiety Disorder

People with Generalized Anxiety Disorder (GAD) spend a great deal of time worrying excessively about many different things.

 

They may be convinced the world is coming to an end or always worry about money, health issues, family members, or their jobs.

 

This disorder can be debilitating if it becomes severe. People with this disorder may be afraid to leave their houses.

 

A study published in 2019 looked at the effects of vitamin D on GAD. Thirty patients with GAD and vitamin D deficiency were split into two groups of 15 patients each. One group received standard of care (SOC) only, while the treatment group received SOC plus 50,000 IU vitamin D weekly for three months.

 

The Generalized Anxiety Disorder 7-Item (GAD-7) scale was used in both groups to measure changes in anxiety levels. The vitamin D group had significant increases in serotonin levels, and their GAD-7 scores also improved. The group receiving SOC only showed no changes in GAD-7 scores or serotonin levels. 

 6

Attention-Deficit/Hyperactivity Disorder

Attention-Deficit/Hyperactivity Disorder (ADHD) is characterized by a persistent pattern of impulsivity, inattention, and or hyperactivity that interferes with occupational, social, or academic functioning. This disorder may begin in infancy and may continue throughout adulthood.

 

The effect of vitamin D on ADHD was studied using fifty ADHD patients and fifty non-ADHD controls. The Conners’ Parent Rating Scale (CPRS) was used to assess ADHD symptoms, and serum 25-hydroxyvitamin D levels were measured using an ELISA kit. 

 

Vitamin D levels were assessed using the following scale:

 

Serum 25OHD less than 10 (severe deficiency)

                                10-29 (mild deficiency)

                                 >30 (sufficient vitamin D level)

 

Patients with ADHD had significantly lower serum levels of vitamin D (16.57 +/- 9.09 ng/ml) compared to the control group (22.01 +/- 12.67 ng/ml).

 

A severe vitamin D deficiency was 3.36 times more likely to be found in the ADHD group. 

 

This study supports the monitoring of vitamin D levels in patients with ADHD.

 7

Tuberculosis

Tuberculosis (TB) is a disease caused by Mycobacterium tuberculosis. This disease mainly affects the lungs but may also affect the kidneys, brain, or spine. It is spread by tiny droplets in the air produced when an infected patient coughs or sneezes. This disease can be life-threatening. 

 

A nested case-control study was conducted looking at the effect of vitamin D on decreasing the progression of tuberculosis (TB).

 

Vitamin D has shown to have some impact on immunity. Vitamin D deficiency may also increase the risk of TB due to its effect on diabetes. Diabetes is a known risk factor for TB, and vitamin D is known to decrease diabetes risk.

 

In this meta-analysis, it was determined that low vitamin D levels were associated with the progression of TB. This effect was found to be dose-dependent. This raises the possibility of using vitamin D supplementation in high-risk populations to help decrease TB risk.

 8

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Alzheimer’s Dementia

A prospective cohort study of 498 older women was conducted in 2012 to determine the effect of vitamin D on dementia. All subjects received baseline cognitive testing utilizing the Pfeiffer Short Portable Mental State Questionnaire. Only those scoring above 8 (normal cognitive function) were included in the study. 

 

After a seven-year period, the Mini-Mental Status Exam (MMSE) and Grober and Buschke test were conducted to screen for dementia. 

It was determined that the subjects with dementia had a lower average vitamin D intake than those without. (50 vs 59 ug/wk).

 

The subjects in the highest vitamin D intake quintile had a lower incidence of dementia than those in the remaining four quintiles combined (4.1% vs. 17%). 

This study did depend on accurate reporting of vitamin D intake by the subjects tested. About half of the subjects were lost to follow-up during the study period.

 

 9

 

Another small randomized controlled study was conducted in 2015 to determine the effect of vitamin D supplementation on the treatment and prevention of Alzheimer’s disease. Subjects were 60 years of age or older with an MMSE score of less than 24. 

 

Two groups were randomized. The active group had a baseline vitamin D level of 8.2 ug/ml. This group received 4,000 IU vitamin D supplementation daily. The control group had a baseline vitamin D level of 9.3 ug/ml and received no vitamin D supplementation.

 

The MMSE was administered every three months. No difference was found between the two groups after three months, but a significant difference occurred after six months (24 vs. 22). Although the sample size was small, a positive effect of vitamin D supplementation was observed.

 10

If you are interested in reading about Lewy Body Dementia follow this link.

 

Depression

I became interested in vitamin D due to its effects on depression. I see a large number of depressed patients and have noticed many have a sub-therapeutic vitamin D level. 

 

People who are depressed feel unhappy most of the time. They may lose interest in things they have enjoyed in the past. Depression can cause the person may sleep too much or too little. They may have a difficult time concentrating and isolate. Depressed patients may have a change in appetite and may have low self-esteem.

 

Researchers believe vitamin D may increase the amount of serotonin in the brain.

 11

 

Increasing serotonin and other monoamines are the mechanisms of action of many antidepressants available today. 

 

Even though there seems to be a link between vitamin D and depression, conflicting evidence still exists.

 12

 

There have been many studies conducted, but it remains unclear whether vitamin D helps treat depression or whether vitamin D levels are just lower in depressed patients. 

 

A study conducted in the Netherlands in 2014 showed low vitamin D levels were associated with the severity and presence of depression. This study followed 1102 depressed patients aged 18-65 years and 790 patients who were not currently depressed but had been in the past.

 13

 

A study in Finland in 2015 found higher serum concentrations of vitamin D were associated with a lower incidence of depression. The investigators believe higher vitamin D levels protect individuals from becoming depressed.

 14

 

I am a firm believer in utilizing vitamin D supplements for those who are depressed. My recommendation is to take 5000 IU daily. Vitamin D levels can be obtained during your yearly health check-up. 

 

Although I am not depressed, I take vitamin D daily to prevent depression. I live in Oregon and don’t get much sun, especially during the winter months. My vitamin D levels have been low in the past. 

 

Can I Take Too Much Vitamin D?

Yes, because vitamin D is a fat-soluble vitamin, it can accumulate. Hypercalcemia, an increased level of calcium in the blood, is the major consequence of taking too much vitamin D. Hypercalcemia can cause nausea, vomiting, frequent urination and weakness. It may also lead to the formation of kidney stones. A person would need to take a very high dose of vitamin D over a long period to become toxic.

Vitamin D is a critical substance used by our bodies in many ways. I have highlighted many uses of this vital vitamin in this post.

 

I have noticed in my practice that a large percentage of depressed patients have a low vitamin D level.  I believe keeping your level therapeutic is a good step in feeling better and helping your body function as efficiently as possible.

I always recommend vitamin D supplementation in any patient with a level less than 30 ng/ml.  It is an easy preventative measure.

If you have any questions or need further information, please feel free to contact me. As always, I want to thank you for reading my blog. If you have any subjects you would like to learn about; please let me know. 

 

We can all live a happy, healthy, healing life! 

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Michael Brown in Lab Coat with arms crossed

Michael J. Brown, RPh, BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.

Read Michael’s story here.

Feel free to send Michael a message using this link.

 

 
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Steroid Induced Psychosis

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Will taking prednisone make you psychotic?

How about other steroids?

Disclosure:  This post may contain affiliate links, meaning, at no additional cost to you, I may earn a commission if you click on, or make a purchase through a third-party link.

What is Psychosis?

Patients with psychosis are not in touch with the real world. They display symptoms of hallucinations and or delusions. They may also speak incoherently or behave in ways that do not fit their current surroundings.

Hallucinations occur when a person senses something that is not there. This can happen with sight, hearing, touch, and smell.

At times, the patient may experience two or more hallucinations simultaneously. For example, a psychotic patient may kneel to pet a dog that doesn’t exist. They can see the dog and feel the dog as they pet it. They may also hear or smell the non-existent animal.

Delusions happen when a person firmly believes something untrue. They may be convinced they are an influential person or someone famous when, in fact, they are not. Delusional patients may think they are younger than their actual age and in better health. They may also suffer from paranoia and swear that people are out to get them.

These patients may only eat packaged food or stop eating entirely due to fear of being poisoned. Delusions are very hard to treat with medication.

Drugs As A Cause Of Psychosis

When a patient presents with new-onset psychosis, it is vital to obtain a thorough history. If a family member has been diagnosed with a psychiatric disorder, there is an increased chance of the illness spreading to other genetic relatives. We also know a patient often responds to the same medications that were effective for family members.

One of the first things I look for as a pharmacist is possible drugs that can cause psychosis. There are several potential agents to consider, but I classify them into two broad groups.

 

 

 

Drugs Of Abuse

These are drugs that are not prescribed by a physician and have a higher incidence of precipitating psychosis. This is true because of the properties of the substance and the erratic dose the patient receives.

Street drugs are not regulated, so drug content is sporadic. The drugs are usually addictive, and individuals take an increasing dose trying to reach the desired effect. Some examples of these agents are:

Cocaine
Methamphetamine
Marijuana
LSD
PCP
Ecstasy
Ethanol

Prescription Medications

The other group contains medications that are available as prescriptions. It is essential to point out that many of these drugs are also available on the street. Any substance that has the ability to alter mood or perception is a candidate for sale on the black market. Some of these agents are:

Antidepressants
Antipsychotics
Anti-seizure medications
Anticholinergic Drugs (Click to read post on anticholinergics)

Isotretinoin
Dopamine agonists for Parkinsons Disease
Corticosteroids

We will concentrate on corticosteroids for this post.

Types Of Steroids

Anabolic Steroids

These include testosterone as well as synthetic substances that are similar in structure to testosterone and have comparable effects. Testosterone is used to treat specific hormone problems in men. The synthetic molecules are often abused by bodybuilders and athletes to build muscle and boost athletic abilities. These are generally not associated with psychosis. Some examples of this type of steroid are:

Dianabol
Winstrol
Deca-durabolin
Equipoise
Anadrol

Corticosteroids

Corticosteroids are used in modern medicine to remedy a variety of conditions.

They are used in the emergency department to treat asthma attacks, COPD, and croup in children.

They can be used to treat Crohn’s disease, gout, lupus, multiple sclerosis, and other autoimmune disorders. Corticosteroids have an important role in reducing inflammation.

These steroids are also utilized in the treatment of skin conditions such as eczema and rash. They play an essential role in some cancer therapies. Corticosteroids come in a variety of forms including injections, tablets, liquids, creams, ointments, and inhalers. Some examples include:

Prednisone
Prednisolone
Dexamethasone
Betamethasone
Triamcinolone
Methylprednisolone

 

 

Corticosteroid Adverse Effects

Unfortunately, although corticosteroids are useful in many of the conditions described above, they can also cause adverse effects. A few common side effects include:

Weight gain
Agitation
Nausea and vomiting
Insomnia
Headache
Mood swings
Euphoria
Psychosis

Steroid Induced Psychosis

Psychosis is a side effect of corticosteroid use and most commonly occurs at prednisone doses above 20mg/day given over a long period. 1 

2 3 

Roughly ten percent of patients remain psychotic after the steroid dose is decreased. 4 

Patients are usually clear after a two-week course of antipsychotic medications.

Although prednisone is often described as the main corticosteroid involved, other members of the steroid family can also cause psychosis.

Dexamethasone

Dexamethasone is often used in place of prednisone due to its longer duration of action. This glucocorticoid is six times more potent than prednisone.

It is unknown what dose of dexamethasone is most likely to cause psychosis, but it has occurred post-operatively after a single dose.

We should anticipate a psychotic reaction after administering dexamethasone, and for surgery cases, it may be prudent to utilize restraints to prevent self-extubation.

Pre-medicating with haloperidol or olanzapine may prove beneficial in this situation. 5 

Dexamethasone will accumulate in the body more quickly than prednisone due to its longer half-life. For this reason, careful monitoring should occur when giving this agent over a more extended period of time.

Methylprednisolone

An article published in European Psychiatry in March of 2016 describes a case where a thirty-year-old female received three, 80mg daily doses of methylprednisolone following lumbar surgery. This patient had no personal or family history of any psychiatric disorder.

One week after the methylprednisolone was completed, the patient was admitted to the hospital for bizarre delusions, visual and auditory hallucinations, and disorganized thinking.

She was treated with risperidone (up to 6mg/day) and a very short course of diazepam (10mg/day). The patient was discharged several weeks later when the psychosis cleared up. 6 

Treatment

The first thing to attempt when treating corticosteroid-induced psychosis is to stop the offending agent. Unfortunately, this is not always possible.

There are circumstances when the steroids must be continued. In these cases, our best option is to treat the patient with an antipsychotic medication.

Which agent we choose is based mostly on the characteristics of the patient. I could write an entire chapter on this subject but will list the agents we utilize most commonly for psychosis on our unit. I will also explain reasons to choose one agent over the other.

Haloperidol

Haloperidol is still widely used due to its familiarity. Physicians like to use what they are most comfortable with.

Some patients should never receive haloperidol. This medication is contraindicated in Parkinson’s patients. Due to its high dopamine (D2) blocking properties, it makes the movement disorder worse.

Haloperidol is still very effective and is often used for delirium as well as psychosis. It is available in oral, injectable and long-acting injectable forms

Quetiapine

Quetiapine is the first choice in a patient who has Parkinson’s disease. This drug is also helpful in patients who are having trouble sleeping as it is one of the most sedating antipsychotics available. Quetiapine is only available in oral dosage forms which limits its usefulness in acute situations.

Olanzapine

Olanzapine is one of the most effective medications we have for delirium as well as psychosis. Like haloperidol, it is also available in all dosage forms.

The main problem with this agent is weight gain. This can be a positive attribute in patients that have a poor appetite, but these days patients tend to be overweight. Olanzapine is usually the medication I initially recommend.

Risperidone

Risperidone is also an effective agent for psychosis, but it is not available in a quick acting injectable form. It can also cause movement disorder side effects, especially at higher doses.

Ziprasidone

Ziprasidone is popular in the emergency department for acute agitation and psychosis due to its availability as a fast-acting injectable. The powder in the vial does take longer to dissolve than olanzapine, and it has cardiac side effects that make it undesirable for elderly patients.

Final Thoughts

There is evidence linking corticosteroid use to psychosis. These medications are used for a variety of ailments. At times, they are needed to treat life-threatening conditions.

Although prednisone is the agent most commonly associated with corticosteroid-induced psychosis, other agents in this class can also lead to psychotic behavior.

It is essential to be aware of the signs of psychosis and seek treatment if you or someone you know is being treated with any of these drugs.

I suggest having someone check on you periodically if you live alone and are taking these medications. Psychotic patients often have no idea they are having a problem until it is discovered by someone else.

If possible, the corticosteroid should be stopped if psychosis develops. If this isn’t prudent, antipsychotic agents can be used based on patient characteristics.

In severe cases, the patient may need to be hospitalized until stable. Most patients will clear after a few days to a couple of weeks.

I hope you have enjoyed this review of corticosteroid-induced psychosis. If you have any questions or comments, please send me an email.

My goal is to make this site as informative and enjoyable as possible for my readers. We can learn the best way to make that happen together.

As always, live a happy, healthy, healing life and remember to HAVE FUN!

 

 

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Michael J. Brown, RPh. BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.
Michael – Sunshine Nutraceuticals (sunshinentc.com)


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Weighted Blankets For Anxiety And Insomnia, The Tapping Method, Squashing Thinking Errors, And Other Anxiety Reducers

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Disclosure:  This post may contain affiliate links, meaning, at no additional cost to you, I may earn a commission if you click on, or make a purchase through a third-party link.

How Can I Stop Feeling So Anxious And Get Some Sleep?

All of us become anxious throughout our lives for different reasons. We may be thinking about a test or speaking engagement and believe we are not prepared.

Our kids may be late getting home or fail to answer their phones. Many of us are afraid of heights or flying in airplanes. Preparing for surgery, being called into the supervisor’s office, getting lost in the woods, can all cause various levels of anxiety.

Anxiety is just a normal part of life.

When fear and anxiety lead to trouble sleeping or problems functioning in daily life, it is time to think about treatment options.

What are some of the options we can accomplish ourselves?


Can we teach ourselves to be less anxious?

 

The answer is yes, and we can. I am going to teach you some ways to decrease your anxiety level.

I used to be much more anxious than I am today. I have read a great deal about anxiety and work in mental health, so I am surrounded by the subject daily.

Weighted Blankets For Anxiety And Insomnia

Weighted blankets are often used in children with autism spectrum disorder (ASD) to provide a “cocooning” feeling. They have also been used in the elderly.

The weighted blanket’s effectiveness has previously been shown to be related to the mass of the person using it. A blanket that weighs more than ten percent of a person’s body is more beneficial.1 

A study published in the Journal of Sleep Medicine & Disorders on May 25, 2015, found a chain-weighted blanket was able to improve the quality of sleep in patients with insomnia. The subjects who used the weighted blanket had a calmer night’s sleep and exhibited less movement throughout the night. They also believed the blanket provided higher quality and a more comfortable night’s sleep.2 

I have the pleasure of sharing an office with Kendra Munroe, OTR-L. Kendra is an Occupational Therapist (OT). She states weighted blankets should not be used in patients with open wounds, broken bones, or a history of sexual trauma.

Kendra prefers to use blankets that weigh no more than ten percent of the patient’s total body weight. She mainly uses weighted blankets from a company called Salt Of The Earth because she states they are well made.

For a more comprehensive explanation of weighted blankets and how to choose the best type for your situation, click here.

The Tapping Method

I also asked Kendra about “The Tapping Method.” This is something I had not been exposed to before working on our unit.

Munroe states this method is usually used for patients with anxiety or depression. It regulates the body by using its natural rhythms. It is best to match the speed of the heartbeat when tapping, according to Kendra.

Kendra recommends not using The Tapping Method on patients who aren’t open to it. It usually won’t work for them.

She excludes those unable to follow a pattern, such as those with dementia, as well as actively manic patients.

Play the video above to learn more.

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Breathing Exercises

The two breathing exercises below can help relieve tension and make you feel more relaxed:

Square Breathing Or Box Breathing

This is a breathing exercise where you:

  1. Breathe in (through your nose) for 4 seconds.
  2. Hold your breath for 4 seconds.
  3. Breathe out (through your mouth) for 4 seconds.
  4. Hold your breath for 4 seconds. 
  5. Repeat sequence. 

Square breathing can help with anxiety and make you feel more relaxed. It can also help with sleep and lower blood pressure.

 

Resonate Breathing Or Coherent Breathing

  1. Lie down in a comfortable place.
  2. Close your eyes and concentrate only on your breathing.
  3. Slowly inhale through your nose for six seconds.
  4. Breath out through your mouth for six seconds.
  5. Repeat the sequence.

These two breathing techniques can help tremendously if practiced. I suggest taking a few minutes each day on the above exercises until they become second nature.  

When you start to feel anxious, proper breathing is an excellent initial intervention for quick relief.

 

Progressive Muscle Relaxation

Progressive muscle relaxation (PMR) is a technique that was developed in the 1920s by a physician attempting to get his patients to relax. This method works by counteracting the effects of the fight-or-flight response. This response helps protect us from danger. 

 In some people, the fight-or-flight response becomes a problem by creating an increase in unnecessary anxiety symptoms. It may even lead to a panic attack at times. 

The adrenalin released during this response increases the heart rate. Stress hormones are also released. This may cause shortness of breath, sweating, trembling, and at times a feeling of impending doom. 

 

Follow these steps to increase relaxation. This exercise may be especially helpful when feeling highly anxious or having a panic attack.

 

  1. Find a comfortable place either sitting or lying down, close your eyes, and take several deep breaths. Try to concentrate only on the air entering and leaving your lungs. If other thoughts come into your mind, gently push them aside. Continue until you start to feel relaxed.
  2. Concentrate on your feet. Tighten the muscles in both of your feet and keep them tight for 10 seconds. Release the tension and pay close attention to how your feet feel. Only think about your feet. After about a minute, go to step three.
  3. Progressively move up your body and repeat step 2 using different muscle groups. Legs, hips, stomach, arms, etc.…
  4. It is essential to try to concentrate exclusively on the muscle group you are working on at the time.

 

Like the breathing techniques mentioned above, this exercise will become more productive with practice. I recommend doing this a couple of times per day until it feels natural. You can then utilize the technique whenever you feel anxious or stressed.

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Guided Imagery

Guided imagery is the use of words to guide a person to imagine a specific scenario designed to bring about the desired effect. This technique is often used to help with pain relief or to reduce stress and anxiety. 

There are many apps available for the iPhone that utilize guided imagery. I am a firm believer in this technique, and if you want the best results, my suggestion is to click on the link below. Healthjourneys has many products available designed explicitly for anxiety relief.

Like the other skills mentioned in this article, guided imagery will become much more effective with practice. Give it a try! 

I am not affiliated with Healthjourneys in any way.

https://www.healthjourneys.com/audio-library/anxiety-relief

Sleep Hygiene

One thing I have learned while working with psychiatric patients is that lack of sleep can make almost any condition worse. 

We all need adequate sleep to recharge our body and mind. I thought this post would be a great place to remind my readers about how to maximize sleep. Here are the general sleep hygiene standards:

 

  1. Do not sleep too much during the day unless you work nights! If you sleep during the day, you will likely not be tired at night. Short naps to recharge are OK, but avoid sleeping for long periods during the day.
  2. Sleep at the same time each night if possible. Establishing a routine is essential. If you can go to sleep at the same time each night and wake up at a similar time each morning, your body will become used to this sleeping routine.
  3. Use your bed for sleep and sex ONLY. Do not read, watch television or eat in your bed.
  4. Exercise, but no too close to bedtime! This is beneficial in several ways. Exercising helps decrease anxiety and depression and will also promote sleep. Two of the best things you can do for your body are to eat healthily and exercise. You will hear much more about this topic in future posts.
  5. Avoid alcohol and caffeine late in the day. Alcohol decreases sleep quality, and caffeine is a stimulant that may make it difficult to fall asleep. I prefer to avoid alcohol entirely, but that is a subject for another post. I try to cut the coffee off early in the afternoon.
  6. Try not to eat right before sleeping. It is best to give your food a chance to digest before closing your eyes for the night! Many foods can cause heartburn which may impact sleep quality. It is also prudent to avoid large amounts of fluid before sleeping because waking up to urinate interrupts sleep.
  7. Expose yourself to sunlight during the day. This can help with sleep as well as depression. Walking around outside during the day helps to maintain a healthy sleep-wake cycle. 
 

Frequent nighttime awakenings and daytime sleepiness are the main signs that you need to work on sleep hygiene. Getting this down can improve your physical and mental health.

Squash the Self-Defeating Thinking Errors

Thinking errors can turn us all into our worst enemies.

There are three broad types of thinking errors. In this article, I am going to explain some of the most common type 2, or self-defeating thinking errors that can lead to depression, anxiety, and general unhappiness.

Catastrophic Thinking

Catastrophic thinking is where one concentrates on the worst-case scenario. This certainly can increase anxiety and prevent the individual from taking appropriate action.

This type of thinking usually has no basis in reality. Consider the following example: 

You call your daughter, but she doesn’t answer her phone. You convince yourself something horrible has happened to her. Maybe she is in the hospital or was involved in a car accident? You have a hard time concentrating and start to get extremely anxious. In reality, she is just away from her phone.

Fortune Telling

Fortune telling happens when the person assumes they will fail before even trying because they have not succeeded in the past. This thinking error is linked to anxiety as well as depression.

An excellent example of this is thinking is: “I will never get the job I just interviewed for.” Without knowing who else applied and exactly what kind of person the company is looking for, you cannot legitimately conclude you won’t get the position.

Negative Focus

The person focuses only on the negative aspects of a situation or person. They may also think negatively about themselves. We have all been around this type of person. They are always complaining about how bad things are.

Mind Reading

Mind reading occurs when a person thinks he knows another person’s thoughts or intentions.

This person may be convinced his friend is thinking about something negative in regards to him. None of us can read minds, so he should confront his friend if he believes they have an issue.  Chances are, the friend doesn’t have an issue at all.  Don’t waste time trying to guess what others are thinking.

There are other thinking errors, but this gives you an idea of how our thoughts can make us anxious.

Exercise To Battle Thinking Errors

Whenever you find yourself thinking about something that might be a thinking error, write it down.

Then next to it, in a separate column, list the reasons the statement is erroneous.

I have done this, and it helps. You will soon start to correct yourself without needing to complete the exercise. It is possible to train our minds to think differently with a little practice.

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Nutraceuticals and Dietary Supplements

There are also natural substances that can help with anxiety as well as depression.  Turmeric, which is a spice used in many foods, has been shown to have many beneficial health-related properties.  For more information, read the article by clicking the link below.

 

https://lyfebotanicals.com/health/turmeric-benefits/

Anxiety is something that will be with us throughout our lives. Although it serves a purpose in keeping us on track and protection us from danger in some situations, it can become overwhelming and detrimental.

The tactics described above can help reduce anxiety and help to increase the quality of your life.

Please remember, if your anxiety becomes too much to handle, or you are unable to function, seek professional help. An anxiety disorder is no different than diabetes or heart disease. It too can get out of control at times and deserves proper treatment.

Anxiety relief is one of my favorite topics. I have learned over the years to control it using the techniques described above.

If you have any questions, please click the contact me link next to my picture below and send me an email. You may also sign up to receive our newsletter by filling out the form on the top of this page.  This contains news about our company, sales on our products, and links to our blog posts.

Remember to have a happy, healthy, healing life.

 

 

Michael Brown in Lab Coat with arms crossed

Michael J. Brown, RPh, BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.

Read Michael’s story here.

Feel free to send Michael a message using this link.

 

 
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Benadryl And Dementia; Can Anticholinergic Drugs Cause Dementia Or Make It Worse?

Posted on by sunshineneutraceuticals

Disclosure:  This post may contain affiliate links, meaning, at no additional cost to you, I may earn a commission if you click on, or make a purchase through a third-party link.

Can Benadryl and other anticholinergic drugs give you dementia?

Dementia has become a national health care crisis. This Disease affects not only patients but also families and caregivers. Early signs of dementia include difficulty writing and speaking, misplacing items, confusion, frustration, and memory loss.

Brain failure is an easy way to describe this Disease.

Alzheimer’s Disease, the most common form of dementia, progresses very slowly. Other types, such as vascular dementia may strike immediately after a stroke. Unfortunately, we are all just one stroke away from becoming a potential dementia patient.

Dementia patients will eventually depend on others for their complete care.

For More Information On Lewy Body Dementia, See My Previous Post By Clicking The Box Below:

Lewy Body Dementia Prognosis, Causes, And Medications To Avoid

What is an anticholinergic drug?

An anticholinergic drug is one that blocks acetylcholine. Acetylcholine is one of the neurotransmitters located in the brain and other parts of the body.

It is quickly destroyed by an enzyme called acetylcholinesterase and has a very short duration of action.

Acetylcholine has many functions:

  • Decreases heart rate, acts as a vasodilator, decreases heart muscle contraction.
  • Causes urinary smooth muscle contraction of the bladder.
  • Helps move food through the digestive tract by increasing peristalsis. 
  • Stimulates gland secretion.
  • Causes bronchoconstriction in the lungs.
  • Effects memory and learning

Anticholinergic Burden

There is no single scale available to rate medications for anticholinergic burden.

More than 600 medications have various levels of anticholinergic effects.1 

In my practice, I primarily use the Beers List and two research articles to get this information.

I will list a few examples in each category below. Please reference the following articles if you require an extensive list of agents:

 

 

 

The two articles I utilize currently are:

  1. Mohammed Saji Salahudeen, Stephen B Duffull & Prasad S Nishtala.Anticholinergic burden quantified by anticholinergic risk scales and adverse outcomes in older people: a systemic review. BMC Geriatrics volume 15, Article number: 31 (2015)

          http://dx.doi.org/10.1186/s12877-015-0029-9

   2.  Durán C, Azermai M, Vander Stichele R. Systematic review of anticholinergic risk scales in older adults. European Journal of Clinical Pharmacology. 2013;69(7):1485-1496. doi:10.1007/s00228-013-1499-3.

          http://dx.doi.org/10.1007/s00228-013-1499-3

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Anticholinergic medications are used for a variety of indications. Some of these are listed below:

Antihistamines

First-generation antihistamines have a high level of anticholinergic activity.

Diphenhydramine (Benadryl) is the most common. This drug is used in its injectable form in hospitals to treat acute allergic reactions along with epinephrine.

It is also used for seasonal allergies, motion sickness, Parkinson’s Disease, and as a sleep aid.

Diphenhydramine is available over the counter (OTC).  Benadryl and memory loss has become a recent study subject.

I tell my patients to steer clear of any OTC medications that end with “PM.”

Most of these products contain diphenhydramine in combination with a pain reliever.

Diphenhydramine is a poor choice to help elderly patients sleep.

Like all anticholinergics, it may lead to blurred vision, dry mouth, and an increased risk of falls.

Antihistamines with high anticholinergic activity:

 

  • Diphenhydramine (Benadryl)
  • Dimenhydrinate (Dramamine) 
  • Cyproheptadine (Periactin)
  • Hydroxyzine (Atarax, Vistaril)

Antidepressants

Antidepressants are primarily used to treat depression and anxiety disorders.

Some antidepressants also possess anticholinergic properties. This is especially true of the older tricyclic antidepressants.

These are rarely used at high doses currently as SSRI’s, such as sertraline (Zoloft) are much safer and have fewer side effects.

Paroxetine (Paxil) is an SSRI that has a higher anticholinergic burden.

It is best to avoid paroxetine in elderly patients.

Antidepressants with high anticholinergic activity:

  • Amitriptyline (Elavil)·
  • Clomipramine (Anafranil)
  • Desipramine (Norpramin)
  • Desipramine (Norpramin)
  • Doxepin (Sinequan)
  • Imipramine (Tofranil)
  • Nortriptyline (Pamelor)
  • Paroxetine (Paxil)

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Antipsychotics

All antipsychotics have some anticholinergic activity. Unfortunately, they are the most effective agents we have for the behavioral and psychological symptoms of dementia, so they are often used in this population.

As with the antidepressants, different agents have various levels of anticholinergic activity. Clozapine (Clozaril) and olanzapine (Zyprexa) are the most anticholinergic atypical antipsychotic agents.

Antipsychotics with high anticholinergic activity:

  • Chlorpromazine (Thorazine)
  • Clozapine (Clozaril)
  • Fluphenazine (Prolixin)
  • Thioridazine (Mellaril)

Urinary antispasmodics

Urinary antispasmodics are indicated for overactive bladder symptoms. The most common is oxybutynin (Ditropan). I have personally witnessed these being used in patients who were incontinent. I believe these drugs should be avoided when possible. These medications should not be used in patients with dementia or delirium. The risk in these cases is likely much higher than the benefit.

GI antispasmodics

Drugs such as dicyclomine are used for irritable bowel syndrome. Many dementia patients are incontinent of bowel as well as urine. These medications should be avoided in this population.

Anticholinergic medications for combating antipsychotic side effects

Benztropine (Cogentin) and trihexyphenidyl (Artane) are used to combat dystonia or pseudo-parkinsonism from antipsychotics.  This is a case where benefit outweighs risk.  These side effects can be debilitating and controlling them is a priority.

Muscle Relaxants

Cyclobenzaprine (Flexeril) and methocarbamol (Robaxin) are used to help with pain and muscle relaxation.

Again, these medications are often necessary for patient comfort.  I suggest using the agent with the lowest anticholinergic burden possible.

Unwanted Side Effects Caused By Anticholinergic Drugs

  • blurred vision
  • dry mouth and eyes
  • constipation
  • dizziness
  • confusion
  • urinary retention
  • Increased risk of falls

Treatment Of Anticholinergic Side Effects

  • Exercise to help relieve constipation.
  • Sugarless candy or gum for dry mouth.
  • Increasing fluid intake for constipation and dry mouth.
  • Saliva substitutes, mouthwashes or fluoride rinses for dry mouth.

Effects Of Aging

As we age, our bodies react differently to medications.

Our liver and kidneys are not as efficient, and we are composed of more fat and less muscle.

We have less protein circulating in our bloodstreams to bind to medications.

We do not excrete drugs as well as a younger person.

All of these factors lead to an increased effect from the medications we ingest.

Dementia patients also have lower acetylcholine levels.2

Anticholinergic medications block a portion of the remaining acetylcholine leading to a further decrease in cognition.

There have been several studies linking anticholinergic medication use to impaired cognitive function in elderly patients.
3
4
5
6
7
8

Clinical Studies On Anticholinergics And Dementia

A clinical review of twenty-seven studies, published in 2009, found all but two discovered an association between the anticholinergic burden of medications and either dementia, delirium, or cognitive impairment.9

 

A study of 1473 individuals without dementia was conducted over a six-year period to determine whether anticholinergic drugs had an effect on memory decline. 

The subjects in this study were between the ages of sixty to ninety years. Several aspects of cognition were measured. 

Even though only 2% of the subjects used anticholinergic drugs (n=29), the results indicate these medications may lead to a more rapid cognitive decline in older adults without dementia. 10

The final study I would like to discuss was the subject of our journal club luncheon last week. 

This is a new nested case-control study of 58,769 dementia patients and 225,574 controls.  

These patients were from England, and data was obtained via the QResearch primary care database.

The purpose of this study was to determine the association between cumulative anticholinergic drug exposure and the risk of dementia.

This study found an increased risk of dementia in patients who used the following types of anticholinergic agents:

  • Antidepressants
  • Bladder antimuscarinics
  • Antipsychotics
  • Anti-epileptic drugs

We were surprised to discover they found no significant increase in dementia risk for:

  • Antihistamines
  • Gastrointestinal antispasmodics
  • Antimuscarinic bronchodilators
  • Antiarrhythmics
  • Skeletal muscle relaxants

 

Our journal club group consisting of three psychiatrists, a psychiatric nurse manager and myself.  We discussed the reason for antihistamines not causing a significant increase in dementia risk.  

As a group, we came up with the following possible explanations:

The information obtained was from drugs dispensed. There is no way to determine if the patients ingested the medications.

Patients may not take antihistamines on a consistent basis. Many times they are only utilized for seasonal allergies or to help with insomnia.

  

Diphenhydramine is available over-the-counter and may not be included in the data obtained by the investigators.

The study also found the link between anticholinergics and dementia was stronger before the age of 80 and in those with vascular dementia as opposed to Alzheimer’s disease.

The increased risk of vascular dementia could be attributed to the anticholinergic agents increasing stroke risk.  

We know that antipsychotics increase the risk of heart disease and stroke as well as diabetes.

I want to point out that this study only looked at medications on the Beers list.

 This list is created by The American Geriatrics Society and lists drugs that should be avoided if possible in geriatric patients.

There are several medications that we often use which are not on this list. Almost all of the antidepressants, with the exception of paroxetine, are rarely used first line.  

Several antipsychotics are also not included. This will undoubtedly affect the study results.

The researchers concluded that there was an almost 50% increase in dementia risk in those who took an equivalent of one single strong anticholinergic medication daily for a three year period.

This leads us to the recommendation that anticholinergic drugs should be avoided when possible, especially in middle-aged and older individuals.

  Physicians and pharmacists should look for alternative agents that have fewer anticholinergic side effects in this patient population.11

I practice as a Clinical Pharmacy Specialist on a psychiatric unit which cares for dementia patients.

As a pharmacist on the unit, one of the first tasks I set out to achieve is to minimize the anticholinergic load of the patient.

I have noticed many patients taking anticholinergic medications unnecessarily.

My suggestion is always to eliminate any medications that are not critical to the patient’s health. This applies to all agents, not only anticholinergics.

There are times when anticholinergic drugs must be used. We can employ the strategies described above to reduce the side effects caused by these agents.

There appears to be an increased risk of developing dementia when taking these medications for an extended period of time.

My recommendation is to use anticholinergic drugs only when clearly indicated.

This applies to all individuals, regardless of age.

Sleep aids and allergy medications should only be used when symptoms are present. This also increases the effectiveness of the agents. The body can become tolerant, especially to sleep aids if used chronically.

The main lesson here is to minimize the use of medications possessing anticholinergic properties.

Michael Brown in Lab Coat with arms crossed

Michael J. Brown, RPh, BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.

Read Michael’s story here.

Feel free to send Michael a message using this link.

 

 
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Hemiplegic Migraine Causes, Treatment, Triggers And Disability

Posted on by sunshineneutraceuticals

Disclosure:  This post may contain affiliate links, meaning, at no additional cost to you, I may earn a commission if you click on, or make a purchase through a third-party link.

Hemiplegic migraine is a severe headache which leads to weakness on one side of the body. As is typical with other migraine headaches, nausea and light sensitivity are also present.  The average frequency of these headaches is three per year.   Some patients experience a few hemiplegic migraines during a lifetime while others get them up to 250 times per year. 

The symptoms of this headache type may lead the sufferer to believe they are having a stroke. The standard stroke symptoms are:

  • Numbness on the side of the body affected
  • Drowsiness
  • Dizziness
  • Visual disturbances, also known as an aura
  • Slurred speech or other speaking difficulties
  • Tingling or numbness on the face, arm or leg of the affected side of the body

In severe cases, patients may need to be hospitalized due to high fever, changes in consciousness or seizure activity.

Two Types Of Hemiplegic Migraine

Familial Hemiplegic Migraine

This type of migraine runs in families and can persist for several generations.  Familial hemiplegic migraine is an autosomal dominant form of migraine. This means the patient may get the abnormal gene from only one parent. It is common for only a single parent to suffer from hemiplegic migraine.

 The following genes are associated with hemiplegic migraine:

  • ATP1A2
  • CACNA1A
  • PRRT2
  • SCN1A

 Mutations in these genes affect neurotransmitter release in the brain. Mutated genes interrupt communication between nerve cells. This lack of communication may lead to visual disturbances and severe migraine headaches.

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Sporadic Hemiplegic Migraine

This type happens to only one individual and is not passed down to future generations. This migraine type is rare. If you experience weakness or other stroke symptoms described above with your headache, seek immediate medical attention.  The headache may be a symptom of a more severe disorder.

Both types of hemiplegic migraine typically begin in childhood. The diagnosis may be difficult because other conditions such as stroke and certain seizure types have similar symptoms.

Patients should visit a neurologist who will obtain a thorough family history, perform imaging tests of the brain and get lab tests as necessary.

Hemiplegic Migraine Triggers

The triggers for these migraine types are thought to be similar to those of other migraines. These triggers include:

  • increased stress
  • consuming caffeine and alcohol
  • intense emotions
  • sleep disturbances
  • not eating regular meals
  • certain food types: processed foods, salty foods, aged cheeses, chocolate, and foods with added MSG
  • changes in the weather
  • bright or flashing lights

It is essential to be aware of the triggers that cause the headache as the most effective treatment for this condition is prevention.

Hemiplegic Migraine Treatment

Non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen (Motrin) and naproxen (Aleve) can be used for acute pain relief. If the pain does not respond to NSAIDS, narcotic analgesics such as Norco (hydrocodone/acetaminophen) or oxycodone may be utilized. 

 Ondansetron can be used for nausea associated with hemiplegic migraine.

 Intranasal ketamine has been shown to decrease the severity and duration of visual disturbances associated with hemiplegic migraine.1

Ergotamines and triptans should not been used for hemiplegic migraine. The FDA has mandated that package labelling for ergotamines (DHE) and triptans (Imitrex) state a contraindication for use in basilar and hemiplegic migraine. This is due to their vasoconstrictive properties, which may lead to vessel spasm and concerns about precipitating a stroke.

  A small study conducted by Mathew et al. in May of 2016 stated the following: BM refers to basilar migraine and HM refers to hemiplegic migraine in the following study conclusion:

“in this retrospective study, triptans and DHE were used with no reported, subsequent acute/subacute ischemic vascular events for the abortive treatment of migraines with basilar and hemiplegic-type features. Although the small sample sizes generated theoretical statistical event rates of 4.5% for BM and 23% for HM, there has been no clear evidence that BM and HM carry an actual elevated risk for vascular events compared with migraine with aura”.

2

This study raises the possibility of utilizing triptans and DHE in the future for hemiplegic migraine treatment. More studies are needed to confirm the safety of these agents for the treatment of this condition.

Prevention

Hemiplegic migraines can be debilitating. If these headaches occur often, it may be necessary to take daily prophylactic medication. There are no randomized controlled trials for hemiplegic migraine prevention, but there are some case reports available. The following drugs have the best evidence for hemiplegic migraine prevention at the current time:

Verapamil

Verapamil has been studied in a limited number of patients for the treatment and prevention of hemiplegic migraine. Four patients with sporadic hemiplegic migraine were given verapamil 120mg one to three times daily. The attacks resolved within two months in two of the patients. A third patient had greater than 50% reduction in headache severity and frequency,

and the fourth patient improved with 5mg verapamil IV followed by 120mg PO verapamil daily. The verapamil had to be discontinued in this patient due to side effects, and the headaches slowly returned to baseline frequency.

3

  It is important to note that other studies have found little to no benefit of verapamil for hemiplegic migraine treatment. 4

Flunarizine

Flunarizine has some evidence for its use in hemiplegic migraine but is unavailable in the United States and Japan.  It is a calcium channel blocker and was originally used to improve blood flow.  It is marketed as the brand name Sibelium.

5

Acetazolamide

Acetazolamide is a medication that has many uses.  It can be used as a “water pill” to help the body excrete excess fluid.  It is used for glaucoma, some types of seizures, and can also be used to prevent altitude sickness in mountain climbers.

Acetazolamide was shown to improve hemiplegic migraine in several case reports. Acetazolamide was dosed at 250 mg twice a day in these studies.

6 7 8

Lamotrigine

Lamotrigine is an anticonvulsant medication used to treat certain types of seizures. It is also used to treat bipolar disorder. Lamotrigine must be started at low doses and titrated to the target dose slowly due to the danger of life-threatening rashes.

Lamotrigine showed benefit in a majority of patients suffering from migraine with aura in a case series of 47 patients. In this study conducted in 2004,  Lamotrigine was reported to be beneficial in the majority of patients, including two who had hemiplegic migraine.

9

In other studies, lamotrigine has had mixed evidence regarding its usefulness in decreasing migraine attack frequency and intensity.

10 11

Based on the data above, the drugs with the best evidence for hemiplegic migraine prevention are verapamil and acetazolamide. Flunarizine may also be used if available. If these agents are ineffective, lamotrigine is an alternative, although evidence is limited to support its use in this condition.

Hemiplegic Migraine Disability

Patients who suffer from hemiplegic migraine headaches may qualify for social security benefits. The Social Security Administration (SSA) does not specify exact guidelines to qualify for benefits regarding migraines.  If you can prove that your headaches prevent you from performing necessary work duties regularly, you may be eligible for SSA benefits.

Some factors the SSA will take into consideration are the following:

  • Ability to concentrate
  • Ability to walk, stand, and lift items
  • Ability to interact with other employees
  • Ability to understand instructions

It is critical to convey the frequency and duration of attacks and the symptoms experienced, which limit the ability to perform any job.

The SSA will also evaluate the severity of the headaches, other medical conditions present, and how often the conditions keep the individual from performing a job.  

This is accomplished by evaluating medical records and a functional report completed by the patient and physician.  It is essential that this form contains a detailed description of how headaches affect job performance.

Keep in mind that the SSA will make their determination based on the ability to perform any full-time job, not necessarily the current position held. If the SSA determines the patient is capable of holding a full-time position, the claim will be denied.




Hemiplegic migraine is a rare condition that can be detrimental to a patient’s life. There are two types, familial which is the genetic form and sporadic. Both types have symptoms similar to a stroke.  If this is a new condition experienced, the sufferer should seek medical attention immediately.

As with classic migraines, there are triggers which may cause headaches. Hemiplegic migraines can be challenging to treat. 

For this reason, I suggest keeping a headache journal. Keep track of activities and food intake before the headache occurred. If specific foods, drinks or activities are found to precipitate migraines, these can be avoided in the future. 

Pay attention to the time of day the headaches occur.  Are there more headaches at different times of the year or when the weather changes?  Do the headaches seem to happen after experiencing loud noises or bright lights?  This information can be important in helping reduce the number of attacks.

Some patients may experience debilitating headaches frequently. It may not be possible for these individuals to perform primary job duties.  It is possible to qualify for SSA disability benefits in some cases.  

As with any medical condition, if the headaches become debilitating, seek medical attention. There may be medications available that can help patients live happier, healthier lives.

Michael Pharmacist

Michael J. Brown, RPh. BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.
Read Michael’s story here. Feel free to send Michael a message using this link


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Lewy Body Dementia Prognosis, Causes, And Medications To Avoid

Posted on by sunshineneutraceuticals

I will explore the prognosis, treatment, progression and features of Lewy Body Dementia (LBD). I have extensive experience with this patient population and will share some of what I have learned over the years. LBD is a devastating disease and is very difficult to treat. Family members attempting to care for these patients often become depressed.

Disclosure:  This post may contain affiliate links, meaning, at no additional cost to you, I may earn a commission if you click on, or make a purchase through a third-party link.

What is LBD?

LBD is the second most prevalent type of dementia behind Alzheimer’s Disease. The Lewy Body Dementia Association (LBDA) estimates 1.3 million Americans have LBD.  The other two types of dementia are vascular dementia and frontotemporal lobe dementia (FTD).  All four dementia types have different diagnostic criteria associated with them.

Causes of LBD

Lewy Body Dementia, caused by the deposition of a protein known as alpha-synuclein in the brain (Lewy bodies), generally affects patients over the age of 50. Prevalence is higher in men than woman. Alpha-synuclein is abundant in the brain tissue of healthy individuals. It is found mainly in presynaptic terminals which are specialized structures on the tips of neurons. When this protein builds up, it can kill or damage neurons responsible for producing acetylcholine and dopamine. Movement, thinking, behaviour and mood are affected by this loss.

Diagnosis of LBD

Abuse of alcohol, prescription or illicit drugs can mimic dementia. Metabolic and thyroid imbalances, as well as delirium, can also produce signs similar to LBD. These should be ruled out before making an LBD diagnosis. 

Vascular dementia caused by stroke, frontotemporal dementia, and Alzheimer’s disease are different disease states and are managed differently with regards to medication.

 Lewy bodies cannot be detected in brain tissue while the patient is living.  The disease can only be confirmed after the patient has passed away, and an autopsy performed.

  The symptoms outlined in the next section, specifically Parkinson’s symptoms and visual hallucinations, are used to diagnose a patient with LBD.

Symptoms of LBD

Dementia

This is progressive confusion. Patients may initially have word-finding difficulties and show some personality changes.  They will misplace items and become easily frustrated.

 Memory loss will become worse over time, and they will be unable to solve problems or learn new skills. During the final stages, they may forget how to eat and drink and will be utterly dependent on others for their care.

REM Sleep Behavior Disorder (RBD)

This is the earliest symptom of LBD in some patients and considered a risk factor for developing it. Dreams, often nightmares, are acted out vocally and physically. Arm and leg movements can be violent during these episodes. 

 The patient may have a difficult time distinguishing dreams from reality when awake.

Parkinson's Disease Symptoms

The classic signs of Parkinson’s disease will likely be present.  These symptoms, along with visual hallucinations, are the core diagnostic criteria which separate Lewy Body Dementia from other dementia types. Parkinson’s symptoms include:

 

  • Tremor: Usually begins in a limb frequently in hands or fingers.
  • Slowed movement or bradykinesia
  • Rigid muscles
  • Poor posture and balance which may cause falls
  • Changes in speech
  • Writing changes
  • Mask facies, as shown by a blank stare. The patient doesn’t show facial emotions.
  • Changes in gait as evidenced by walking with stiff legs or shuffling

Fluctuations in cognition

The patient may be alert one minute and confused the next. Changes can happen at any time and may go on for hours or days.  These symptoms resemble delirium.

 

Hallucinations

These are most commonly visual and may or may not be disturbing to the patient. The patient may report seeing children or animals. They are often more severe when the patient is confused. Hallucinations occur in approximately 80% of LBD patients.

 

Treatment

It is vital to utilize a care team when treating this condition. Cognitive-behavioural therapy (CBT) is used early in the disease process. As the patient progresses, CBT is less beneficial due to a decline in cognition.  LBD cannot be cured or prevented, but the following professionals can help the patient:

Speech Therapist

Can help the patient with difficulty swallowing. The therapist can also help the patient speak more loudly and clearly.

 

Occupational Therapist

Assists patients with daily activities and mobilization.   Sets up the patients living area to limit frustration and creates a daily routine for the patient to follow.  Can help care-givers with tips on how to manage various behaviours.

Physical Therapist

helps with exercises to strengthen the body and improve gait.

Art and Music Therapists

Dementia patients can often remember and enjoy music and art they experienced in the past. The art and music can help expression, which improves concentration and can ease frustration.

Psychiatrists and Psychiatric Nurses

If the patient becomes aggressive, violent or otherwise hard to manage, there may be a need for hospitalization. These professionals can develop a treatment plan with help from the professionals listed above. Specialized inpatient units exist to treat these patients.

Palliative care Physicians and Nurses

These professionals may be useful during any stage of the disease, and are especially valuable when the patient reaches the final stages. Keeping the patient comfortable becomes the most important goal at this time.

Medication Therapy

Anticholinesterase inhibitors (ACHEI's)

ACHEI’s can be useful in LBD, although Cochrane database reviews have shown mixed results. Rivastigmine is a popular ACHEI choice for these patients, due to its availability as a transdermal patch.  Donepezil may also be used and is often the ACHEI the physician utilizes at the beginning of treatment.  It is important to stress that these medications are not a cure for the disease. They are only useful in slowing its progression.

 

Memantine has been shown to increase the quality of life scores in LBD patients. Memantine may improve memory and awareness. Memantine has little effect during the final stages of the disease.

Antipsychotics

It is important to note that antipsychotic medications can make LBD patients worse. The Parkinson’s symptoms present in this disease are due to a decrease in dopamine in the substantia nigra region of the brain. 

Antipsychotics work by blocking dopamine receptors. This blockade creates a further reduction in dopamine and thus makes the movement disorder worse.

Behavioural and Psychological Symptoms of Dementia

Antipsychotic medications are often used in dementia patients to treat behavioural and psychological symptoms of dementia. These are the symptoms that lead to hospitalization and include the following:

  • Apathy: Lacks feeling or emotion.

 

  • Delusions: Believing something that is not real. They may believe they are an influential person or believe that they are being followed, watched, or poisoned, for example.

 

  • Aggression: Striking out or yelling at others. Aggression can be new behaviour for these patients.

 

  • Agitation: Can be restless or appear nervous.

 

  • Anxiety: Apprehensive or uneasy. May show signs of fear (rapid heart rate, sweating, trembling)

 

  • Movement disturbances: The patient may pace or move in unnatural ways with no determined purpose. 

 

  • Irritability: Becomes frustrated or upset quickly.

 

  • Lability: Patients may experience rapid changes in mood for no apparent reason.They may laugh one minute and cry the next.

 

  • Sleep/Wake disturbances: Patient may not sleep, or the sleep/wake cycle may be reversed.This can pose a significant problem for care-givers.

 

  • Depression: the feeling of sadness. The patient may isolate to room.

 

  • Dysphoria: Dissatisfaction with life in general.

 

  • Hypersexuality or disinhibition: May touch or try to kiss others. Acts without thoughts of consequences.

 

  • Sundowning: More common in Alzheimer’s dementia. The patient becomes agitation or aggressive late in the day.

 

Hallucinations: Visual, auditory, or tactile sensations that are perceived but not real. Visual hallucinations are a diagnostic sign

If antipsychotics are used in LBD patients, quetiapine or clozapine should be utilized due to lower dopamine blocking activity. Haloperidol should NEVER be used in these patients. 

Prognosis

The average lifespan of a patient with LBD is 5 to 8 years after the diagnosis.  Patients can live up to 20 years with the disease, but this is very uncommon.

 Patients become weak near the end of life and may succumb to pneumonia or other opportunistic infections.  They may be unable to swallow, and tube feeding is a poor option for these patients.

Lewy Body Dementia is a devastating condition for the patient, family and care-givers. Below are some helpful hints to keep in mind when caring for these patients.

  • Try not to give the patient tasks or activities that are challenging to complete. Difficult chores can lead to frustration and negative behaviour.
  • Utilize professionals who have experience with this type of patient. 
  • Try to keep the patient’s routine as consistent as possible. Changing practices can cause frustration.
  • Have the patient listen to music they enjoyed in the past or show them pictures of family and friends to help calm them.
  • If the patient becomes aggressive, violent or challenging to manage, get help! Getting burned out does not help the patient or care-giver. Many individuals caring for dementia patients become depressed.  If you are caring for one of these patients, be sure to take care of yourself. Get exercise, eat well, get plenty of sleep and take breaks as needed.  
  • During the final stages, it may be necessary to move the patient to a memory care facility. These facilities specialize in dementia care.

If you have any questions or would like additional information, please feel free to reach out to me using the link below.  If I do not know the answer to your question, I will find it for you. 

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Always remember to live a happy, healthy, healing life!

Michael Pharmacist

Michael J. Brown, RPh. BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.
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