Concomitant Prescribing Of Opioid Analgesics And Benzodiazepines
Concomitant use of benzodiazepines and opioid analgesics creates significant risk for opioid-related harm and overdose deaths. Three studies of fatal overdose deaths found evidence of concurrent benzodiazepine use in 31 to 61 percent of decedents . In addition, emergency visits and substance abuse treatment admissions involving the combined use of these two drug classes are also increasing .;
Nearly all recent opioid prescribing guidelines recommend against the concomitant use or prescribing of opioids and benzodiazepines, yet concomitancy remains common. A recent study of concomitant use found that the proportion of opioid users who were co-prescribed benzodiazepines nearly doubled from 9 percent in 2001 to 17 percent in 2013 . Clinicians should be extremely cautious about concomitant prescribing and use among their patients. Check with the PMP for current benzodiazepine use frequently and inquire about intermittent use when prescribing opioid analgesic therapy.;
Are There Different Kinds Of Migraines
Yes. The most common are classic migraines and common migraines.
Classic migraines start with a warning sign called an aura . An aura can change the way you see things. You may see flashing lights and colors, or you might not be able to see things to your side. Auras last about 15 to 30 minutes. Pain usually comes after the aura, but sometimes the pain and aura happen at the same time, or the pain never happens. The pain of classic migraines might be on one side of your head or on both sides. You may also have a strange prickly or burning feeling, or feel weak on one side of your body. You may have trouble talking. You may also feel depressed, grouchy, and restless.
Common migraines dont start with an aura. Common migraines may start more slowly than classic migraines and last longer. The pain of common migraines may be on only one side of your head.
What Causes Migraine Headaches
Migraine headaches seem to be caused by changes in the amount of a chemical called serotonin you have in your body. When serotonin levels are high, your blood vessels shrink. When serotonin levels are low, your blood vessels swell. This swelling can cause pain and other problems. Many things can affect the level of serotonin in your body, including certain foods and your level of blood sugar. In women, changes in the amount of a hormone called estrogen can affect serotonin levels.
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Important Information About All Medicines
Never take more than the prescribed dose. If you suspect that you or someone else might have taken an overdose of this medicine, go to the accident and emergency department of your local hospital. Take the container with you, even if it is empty.
This medicine is for you. Never give it to other people even if their condition appears to be the same as yours.
If you buy any medicines, check with a pharmacist that they are suitable to take with your other medicines.
If you are having an operation or any dental treatment, tell the person carrying out the treatment which medicines you are taking.
Do not keep out-of-date or unwanted medicines. Take them to your local pharmacy which will dispose of them for you.
If you have any questions about this medicine, ask your pharmacist.
Further reading and references
Medicines For Migraine When Pregnant Or Breastfeeding
Many of the medicines used to treat migraine should not be taken by pregnant or breastfeeding women.
- For relief of a migraine headache:
- Paracetamol is the medicine most commonly used, as it is known to be safe during pregnancy.
- Ibuprofen is sometimes used but do not take it in the last third of the pregnancy .
- Aspirin – avoid if you are trying to conceive, early in pregnancy, in the third trimester and whilst breastfeeding.
- Triptans – should not be taken by pregnant women at all. Triptans can be used during breastfeeding, but milk should be expressed and discarded for 12-24 hours after the dose .
Check with your pharmacist or doctor if you are not sure.
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How Exactly Does Taking Headache Medication Too Often Cause Medication Overuse Headache
When you get headaches, you most likely take your acute medication. However, if your headaches are not well controlled and you develop more headaches, you will take more and more as-needed medication to manage your headache. So this vicious cycle of taking more and more pain-relieving medications to lesson your headache actually leads to the development of daily or nearly daily headaches.
Technically, medication overuse headache is defined as having headaches on 15 or more days a month in someone who has a preexisting headache disorder who has been taking one or more acute medications to relieve symptoms for at least three months and who has no other known cause for their headache.
Important Safety Information Including Boxed Warning
WARNING: DISTANT SPREAD OF TOXIN EFFECT
Postmarketing reports indicate that the effects of BOTOX® and all botulinum toxin products may spread from the area of injection to produce symptoms consistent with botulinum toxin effects. These may include asthenia, generalized muscle weakness, diplopia, ptosis, dysphagia, dysphonia, dysarthria, urinary incontinence, and breathing difficulties. These symptoms have been reported hours to weeks after injection. Swallowing and breathing difficulties can be life threatening, and there have been reports of death. The risk of symptoms is probably greatest in children treated for spasticity, but symptoms can also occur in adults treated for spasticity and other conditions, particularly in those patients who have an underlying condition that would predispose them to these symptoms. In unapproved uses and approved indications, cases of spread of effect have been reported at doses comparable to those used to treat Cervical Dystonia and spasticity and at lower doses.
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How Are Headaches Evaluated And Diagnosed In Children And Adolescents
Headache history. Gathering details about the headaches is key to diagnosis and for creating an effective treatment plan. The headache history should be obtained from both the child and his or her parents. Questions you will be asked include:
- How the headaches started
- How long the headaches have been present
- Whether there is a single type of headache or multiple types of headaches
- How often the headaches occur and if they are becoming more frequent
- What triggers the headaches, if known
- If physical activity aggravates the headache pain
- What other symptoms are associated with the headache
- Who else in your family has headaches
- What symptoms, if any, occur between headaches
Your doctor will also ask questions about how well the child is performing at school, any history of substance abuse, and other medical problems.
Clinical description of headaches. The patient will be asked to describe how he or she feels when a headache occurs. Questions you will be asked include:
- Where the pain is located
- What does the pain feel like
- How severe is the headache pain, using a scale from 1 to 10
- If the headaches appear suddenly without warning or with other symptoms
- What time of day the headache usually occurs
- If there is an aura before the headache
- What other symptoms occur with a headache
- How long the headache lasts
- What makes it feel better
Consultation with other specialists. Your doctor may request consultation with other specialist to obtain additional information including:
Botulinum Toxin Injections To Prevent Migraine
In July 2010 the Medicines and Healthcare products Regulatory Agency licensed the use of botulinum toxin injections for the prevention of migraine. This decision was based on research studies that seemed to show it to be an effective treatment at reducing the number of migraine attacks .
Treatment consists of up to five courses of treatment with botulinum toxin injections every 12 weeks. The injections are given into muscles around the head and neck. It is not clear how this treatment may work for migraine. Botulinum toxin relaxes muscles but it may also have some sort of action to block pain signals. The theory is that these actions may have an effect of stopping a migraine headache from being triggered.
In 2012, guidelines were issued by NICE on this treatment. NICE recommends botulinum toxin type A as a possible treatment for preventing headaches in some adults with persistent migraine. The criteria set down by NICE for people who may be considered for this treatment are:
- If you have chronic migraine ; and
- You have already tried at least three different medicine treatments to prevent your chronic migraine headaches, but these have not worked; and
- You are not taking too many painkillers or using them too often.
Also, treatment should be stopped if:
How to use the Yellow Card Scheme
If you think you have had a side-effect to one of your medicines you can report this on the Yellow Card Scheme. You can do this online at www.mhra.gov.uk/yellowcard.
- The side-effect.
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How Common Are Headaches In Children And Adolescents
Headaches are common in children and adolescents. Among children ages 5 to 17 years of age, 20% have reported getting headaches. The most common types of headaches in this age group are tension headaches and migraine . Many parents worry that their childs headache is the sign of a brain tumor or serious medical condition. However, less than 3% of headaches are the result of these conditions. Many headaches in children and adolescents are the result of stress and lifestyle issues.
What Other Information Should I Know
Keep all appointments with your doctor. Your blood pressure should be checked regularly.
You should keep a headache diary by writing down when you have headaches and when you take sumatriptan.
Do not let anyone else take your medication. Ask your pharmacist any questions you have about refilling your prescription.
It is important for you to keep a written list of all of the prescription and nonprescription medicines you are taking, as well as any products such as vitamins, minerals, or other dietary supplements. You should bring this list with you each time you visit a doctor or if you are admitted to a hospital. It is also important information to carry with you in case of emergencies.
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Indications Adult Bladder Dysfunction:
Overactive Bladder BOTOX® for injection is indicated for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency in adults who have an inadequate response to or are intolerant of an anticholinergic medication.
Detrusor Overactivity Associated With a Neurologic Condition BOTOX® is indicated for the treatment of urinary incontinence due to detrusor overactivity associated with a neurologic condition in adults who have an inadequate response to or are intolerant of an anticholinergic medication.
Important Safety Information Contraindications
BOTOX® is contraindicated in the presence of infection at the proposed injection site and in patients who are hypersensitive to any botulinum toxin product or to any of the components in the formulation.
BOTOX® is contraindicated for intradetrusor injection in patients with a urinary tract infection, or in patients with urinary retention, or post-void residual urine volume > 200 mL who are not routinely performing clean intermittent self-catheterization .
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Medicines Plus Behavioural Therapy
An interesting research study published in 2010 compared two groups of people who had frequent migraines. One group took a beta-blocker medicine alone. Another group took a beta-blocker but also had a course of behavioural migraine management . BMM included education about migraine, helping to identify and manage migraine triggers, relaxation techniques and stress management. After a number of months the group of people who took the beta-blocker plus BMM had, on average, significantly fewer migraines compared with the group who took beta-blockers alone. Further research is needed to confirm this and to look at BMM combined with other medicines to prevent migraine.
Who Should Take A Medicine To Prevent Migraine Attacks
There is no definite rule. For example, you may wish to consider this option if you have:
- More than two migraine attacks per month that cause significant disruption to your life.
- Less frequent, but severe, migraine attacks.
- The need to use a lot of painkillers or triptan medicines to treat migraine attacks.
- Painkillers or triptans for migraine attacks not working very well, or you are unable to take them because of side-effects or other problems.
Before embarking on preventative treatment, it is probably best to keep a migraine diary for a few months to assess:
- How often and how bad your migraine attacks are.
- Your current use of medication to treat the migraine attacks.
This may help you to decide if preventative treatment is worth a try, and also to help assess if you may have medication-induced headache. See the leaflet called Migraine trigger diary, including a migraine diary that you may like to print out and use.
How Should This Medicine Be Used
Sumatriptan comes as a tablet to take by mouth. It is usually taken at the first sign of a migraine headache.If your symptoms improve after you take sumatriptan but return after 2 hours or longer, you may take a second tablet. However, if your symptoms do not improve after you take sumitriptan, do not take a second tablet without calling your doctor. Your doctor will tell you the maximum number of tablets you may take in a 24-hour period.Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take sumatriptan exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor.
You may take your first dose of sumatriptan in a doctor’s office or other medical facility where you can be monitored for serious reactions.
If you take sumatriptan more often or for longer than the recommended period of time, your headaches may get worse or may occur more frequently. You should not take sumatriptan or any other headache medication for more than 10 days per month. Call your doctor if you need to take sumatriptan to treat more than four headaches in a 1-month period.
Ask your pharmacist or doctor for a copy of the manufacturer’s information for the patient.
What Are The Treatment Options To Prevent Menstrual Migraine
Medications used to treat menstrual migraine are the same as those used to treat other forms of migraine. However, your doctor may recommend other treatments to be take regularly, in order to prevent or reduce the severity and frequency of menstrual migraines.
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Medicines For Treatment Of Migraine Attacks
There are four types of medicines that are commonly used to treat migraine attacks:
- Ordinary painkillers – eg, paracetamol.
- Anti-inflammatory painkillers – eg, aspirin, ibuprofen
- Anti-sickness medicines – eg, domperidone, prochlorperazine
- Triptans – eg, almotriptan, naratriptan,;sumatriptan,;zolmitriptan
General Principles Of Preventive Treatment
Successful management of migraine rests on an effective alliance between the doctor and the patient, and on effective patient education: the diagnosis must be carefully explained to the patient from the outset and it must be properly understood. In this way, realistic expectations can be set. Patient-compiled headache diaries can be very valuable tools for planning and evaluating treatment. The availability of a carefully kept record of days with headache, pain severity, medication use and response, as well as obvious triggers , can be vital in determining the need for preventive strategies and in evaluating therapeutic outcomes . Disability scales, such as the Migraine Disability Assessment Score , are important instruments for evaluating the impact of headache on a patients daily life. The Headache Under-Response to Treatment questionnaire allows even non-expert clinicians to measure the effectiveness of a headache treatment .
Migraine is a highly heterogeneous condition and its treatment should be tailored to the individual patient. After explaining the diagnosis, the physician should encourage the patient to actively participate in assessing how his/her lifestyle and behaviours may contribute to his/her condition; patients should also be encouraged to explore non-pharmacological approaches whose effectiveness in migraine prevention is well documented, such as biofeedback, relaxation therapy and cognitive behavioural therapies.
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Diagnosis And Patient Assessment
Migraine has well-established diagnostic criteria4; . Good evidence supports the use of the POUND mnemonic for migraine diagnosis6; . Assessment aims to confirm diagnostic criteria, evaluate for alternative explanations, identify comorbidities that could complicate management ,8; and document the baseline pattern and severity of episodes. A variety of conditions can present as headache, most of which can be identified by the history and physical examination .6 The only indications for ancillary testing are to identify causes of secondary headaches or comorbid conditions.9,10; Table 4 lists red flag symptoms that indicate the need for neuroimaging and/or urgent referral.9,10
International Headache Society Diagnostic Criteria for Migraine Headache With and Without Aura
Migraine without aura
*Recurrent disorder manifesting in headaches with reversible focal neurologic symptoms that usually develop gradually over 5 to 20 minutes before onset of the headache and last for less than 60 minutes. Headache with the features of migraine without aura usually follows the aura symptoms. Less commonly, headache lacks migrainous features or is completely absent .
Adapted with permission from Gilmore B, Michael M. Treatment of acute migraine headache . Am Fam Physician. 2011;83:272.
International Headache Society Diagnostic Criteria for Migraine Headache With and Without Aura
Migraine without aura
POUND Mnemonic for Diagnosis of Migraine