Ketamine May Help Treat Medically Refractory Migraine Pain
Ketamine, a medication commonly used for pain relief and increasingly used for depression, may help alleviate migraine pain in patients who have not been helped by other treatments, a study suggests.
The trial of 61 patients found that almost 75% had an improvement in their migraine intensity after a three- to seven-day course of inpatient treatment with ketamine. The drug is used to induce general anesthesia, but also provides powerful pain control for patients with many painful conditions in lower doses than its anesthetic use.
“Ketamine may hold promise as a treatment for migraine headaches in patients who have failed other treatments,” said study coauthor Eric Schwenk, MD, Director of Orthopedic Anesthesia at Thomas Jefferson University Hospital in Philadelphia. “Our study focused only on short-term relief, but it is encouraging that this treatment might have the potential to help patients [in the] long-term. Our work provides the basis for future prospective studies that involve larger numbers of patients.”
An estimated 12% of the US population has migraines. A subset of these patients, along with those who have other types of headaches, does not respond to treatment. During a migraine, people are often sensitive to light and sound and may become nauseated or vomit. Migraines are three times more common in women than in men.
The researchers reviewed data for patients who received ketamine infusions for intractable migraine headaches—migraines that had failed all other therapies. On a scale of 0 to 10, the average migraine headache pain rating at admission was 7.5, compared with 3.4 at discharge. The average length of infusion was 5.1 days, and the day of lowest pain ratings was day 4. Adverse effects were generally mild.
Dr. Schwenk said that while his hospital uses ketamine to treat intractable migraines, the treatment is not yet widely available. Thomas Jefferson University Hospital will open a new infusion center that will treat more patients with headaches using ketamine. “We hope to expand its use to both more patients and more conditions in the future,” he said.
“Due to the retrospective nature of the study, we cannot definitively say that ketamine is entirely responsible for the pain relief, but we have provided a basis for additional larger studies to be undertaken,” Dr. Schwenk added.
Opioid Abuse Plateaus at a High Level
Although the rapid increase in opioid abuse has leveled off, the prevalence of abuse remains high and does not appear to be declining, according to an analysis of national data.
More than 13% of Americans age 12 and older—nearly one in seven—have abused prescription opioids at some point in their lives, researchers determined after analyzing the latest data from the National Survey on Drug Use and Health (NSDUH), an annual survey sponsored by the Substance Abuse and Mental Health Services Administration. Additionally, while 8.6% of Americans abused opioids in 2000, by 2003 that number increased to 13.2%, and it has remained at that level since.
“The amount of opioid prescriptions being written in the United States is breathtaking—essentially enough for every American adult to have a bottle of the pain killers in their medicine cabinet,” said Asokumar Buvanendran, MD, lead author of the study, Director of Orthopedic Anesthesia and Vice Chair for Research at Rush Medical College in Chicago, and chair of the American Society of Anesthesiologists (ASA) Committee on Pain Medicine. “This in turn leads to opioid abuse because people may take more than needed, or the pills fall into the wrong hands. That has got to change.”
Because opioids can produce euphoria, they are highly likely to be abused. Opioid prescriptions are often written for an excessive number of pills, so patients may take more medication than they need and become addicted. Additionally, unused medication can be diverted to another person for illicit use. More than half of the people who misuse prescribed opioids get them from a friend or relative, not a physician, according to NSDUH data.
The NSDUH survey asked Americans whether they had taken prescription opioids without a prescription written for them (which constitutes abuse) anytime in their lives. The researchers determined that in 2014 (the last year for which data was available), 13.6% of Americans had abused prescription opioids. Use of hydrocodone (including Vicodin, a combination of hydrocodone and acetaminophen) increased from 3.2% in 2000 to 9.1% in 2014. Use of oxycontin increased from less than 1% in 2000 to 3% in 2014.
Hydrocodone is the most frequently prescribed and therefore the most frequently abused opioid, researchers noted.
“While the illicit opioid use trend seems to have plateaued, there is no evidence of a decline yet,” said Mario Moric, coauthor of the study and a biostatistician at Rush Medical College. “Hopefully, with increased national attention to the problem we will see a significant drop in abuse.”
“Opioids are still an important tool for dealing with pain, but doctors need to prescribe smaller quantities,” said Dr. Buvanendran. “Also, patients need to be educated about the dangers of overuse and abuse and understand that pain usually cannot be solved solely with a pill, but needs to include exercise, physical therapy, eating right, having a social support system, and developing good coping skills.”
The ASA is committed to ending opioid abuse and has launched several initiatives to combat the epidemic.
Botox May Benefit Children With Hard-to-Treat Migraines
Injections of botulinum toxin (Botox) may provide significant relief for children with migraine headaches that do not respond to traditional treatment, suggests a small preliminary study.
Botox is approved by the FDA to treat migraines in adults. One in 10 school-aged children and teens have migraines, but there are few FDA-approved medications for this age group. Some children and teens do not respond well to available options, such as certain migraine rescue pain medications, and the pain and disability of migraines can have a severe impact on their lives. Preventative medications may help sometimes. Only one preventative migraine medication, topiramate, is approved for adolescents, however.
“When children and teens have migraine pain, it can severely affect their lives and ability to function. They miss school, their grades suffer, and they are left behind, often unable to reach their full potential. Clearly, there is a need for an alternative treatment for those who have not found relief,” said Shalini Shah, MD, lead author of the study and Chief of the Division of Pain Medicine at the University of California, Irvine. “After treatment, we saw improvement in functional aspects in all of the children and teens. In fact, one patient was hospitalized monthly for her migraine pain prior to Botox treatment and was expected to be held back in school. After treatment, she only has one or two migraines a year, and is excelling in college.”
The study included nine children and teens (ages 8 to 17) who had migraines on eight to 29.5 days per month. Most participants had tried numerous medications and other therapies without much relief. All received Botox injections in the front and back of the head and neck every 12 weeks and were evaluated during a five-year period. After treatment, the patients had migraines on two to 10 days per month.
In addition, when treated participants did have migraines, their headaches did not last as long. Patients’ migraines lasted from 30 minutes to 24 hours before treatment, and 15 minutes to seven hours after treatment. Their headaches also were not as painful. Patient-reported pain on a scale of 1–10 (from no pain to worst pain imaginable) ranged from 4 to 8 before treatment and 1.75 to 5 after treatment.
Eight adverse events were reported during the study. Most resulted from pain at the injection site. No severe adverse events were reported.
If the results of the current study are confirmed, Botox could provide an alternative for patients without treatment options, said Dr. Shah. Her team is enrolling patients to study this treatment in a prospective, randomized, double-blinded trial to compare Botox with placebo.
“Many current migraine medications have side effects, including sedation, dry mouth, and confusion, which are not well-tolerated in children and teens,” said Dr. Shah. “Our research of Botox is part of an effort to find better treatments for children and teens with migraines so they can realize their full potential.”
The study authors received no funding from the manufacturer of Botox.
Diabetes Increases Risk of Cognitive Problems After Surgery
Older patients with diabetes may be at an 84% higher risk of developing postoperative cognitive dysfunction (POCD) than those who are not diabetic, new research suggests.
“With POCD, a patient’s mental ability declines after surgery, compared to their cognitive performance before surgery, resulting not only in increased complications and potential death, but also impairing the patient’s quality of life,” said Gunnar Lachmann, MD, Department of Anesthesiology and Operative Intensive Care Medicine, Charité—Universitätsmedizin Berlin. “POCD is increasingly recognized as a common complication after major surgery, affecting 10% to 13% of patients, with seniors being especially vulnerable.”
POCD is a major form of cognitive disturbance that can occur after anesthesia and surgery, but little is known about its potential risk factors. An association between diabetes and age-related cognitive impairment is well established, but the role diabetes has in the development of POCD is unknown.
In the study, researchers performed a secondary analysis of three studies, comprising 1,034 patients (481 who had cardiac surgery and 553 who had noncardiac surgery), to examine whether diabetes was a risk factor for POCD. Patients’ mean age was 66.4. Of the 1,034 participants, 18.6% had diabetes. The association of diabetes with risk of POCD was determined using logistic regression models at the longest patient follow-up period for each study, which was three or 12 months. Risk estimates were pooled across all three studies.
After adjusting for age, sex, surgery type, randomization, obesity, and hypertension, the researchers determined that diabetes was associated with an 84% higher risk of POCD. Patients age 65 or older were at particularly high risk.
“Our findings suggest that consideration of diabetes status may be helpful for the assessment of POCD risk among patients undergoing surgery,” said Dr. Lachmann. “Further studies are warranted to examine the potential mechanisms of this association, to ultimately help in the development of potential strategies for prevention.”
In 2015, the American Society of Anesthesiologists launched a patient safety initiative—the Brain Health Initiative—to provide physician anesthesiologists and other clinicians involved in perioperative care, as well as patients and their families caring for older surgical patients, with the tools and resources necessary to optimize the cognitive recovery and perioperative experience for adults age 65 and older undergoing surgery.