The Role of Gabapentin in Pain Management

Opioids, non‐steroidal anti‐inflammatory drugs (NSAIDs), antidepressants, and anticonvulsants are used as pharmacological agents to treat pain. However, no single class of drugs has been found to be effective in all types of pain, presumably because pain syndromes involve different mechanisms.

In addition, each of the currently available drugs is associated with adverse effects, some of which are potentially serious or life‐threatening such as idiosyncratic or toxic reactions.

Traditionally, the treatment of neuropathic pain has involved anticonvulsants, such as carbemazepine, valproic acid and phenytoin, and tricyclic antidepressants, such as amitriptyline and nortriptyline and doxepin. The main disadvantages of the anticonvulsants are their potential for drug interactions via the induction of hepatic enzymes, or resulting from inhibition of hepatic enzymes by other drugs. Minor side‐effects such as sedation, ataxia, vertigo and diplopia are associated with carbemazepine and phenytoin, whereas, anorexia, nausea, vomiting and tremor are associated with valproic acid. Chronic phenytoin use may cause peripheral neuropathy (30%) and gingival hyperplasia (20%), and fetal hydantoin syndrome if administered during pregnancy. Carbemazepine can cause chronic diarrhoea or the syndrome of inappropriate ADH secretion, and rarely aplastic anaemia, thrombocytopaenia, hepatocellular jaundice and cardiac arrhythmias.

Tricyclic antidepressants also cause side‐effects that can be troublesome or potentially dangerous, such as anticholinergic effects (dry mouth, blurred vision, urinary retention, ileus), sedation, orthostatic hypotension, tachycardia and atrio‐ventricular conduction disturbances. Such adverse effects are likely to reduce the tolerance of this group of drugs in elderly or unwell patients. Some subgroups of patients with painful neuropathy such as diabetes may also have autonomic neuropathy and may not tolerate the orthostatic hypotension associated with tricyclic antidepressants.

With increasing evidence of the efficacy of gabapentin in a wide variety of pain syndromes, especially neuropathic pain, gabapentin may be potentially useful because of its relative freedom from serious adverse effects, its lack of interactions with other drugs and its lack of potential for causing drug dependence.

A comparison of the evidence available of efficacy and toxicity for anticonvulsants (gabapentin, phenytoin and carbemazepine) and antidepressants (tricyclic antidepressants and SSRIs) in patients with diabetic neuropathy and postherpetic neuralgia has recently been made by Collins et al. [129] These two neuropathic pain conditions were chosen according to strict diagnostic criteria. Although two previous systematic reviews of anticonvulsants and antidepressants in diabetic neuropathy showed no significant difference in efficacy or adverse effects between the two drug classes [130, 131], Collins et al. found that when data from randomised controlled trials for both diabetic neuropathy and postherpetic neuralgia were pooled, the NNT for at least 50% pain relief was identical for both classes of drugs. When gabapentin was compared with other anticonvulsants, there was no significant difference in efficacy.

The NNT for gabapentin was 3.4 compared with 2.2 for phenytoin/carbemazepine. The number needed to harm (NNH, defined as the number needed to harm one patient from the therapy) for minor adverse effects was 2.7 for both antidepressants and anticonvulsants. Collins et al. used two trials to provide data on minor adverse effects for gabapentin and two trials for phenytoin. The NNH (minor adverse effects) was 2.6 similar to that of gabapentin and 3.2 for phenytoin. The NNH (major adverse effects) for the tricyclic antidepressants was 17, and no significant difference in the incidence of major adverse effects was found between anticonvulsants and placebo.

Collins et al. suggested that the difference in the incidence of major adverse effects can be compared by using the ratio between treatment specific benefit and treatment specific harm (defined as the number of patients needed to experience at least 50% benefit for one to experience a major adverse effect that warranted discontinuation of treatment). The ratio for gabapentin was 6 compared with an average of 8 for all anticonvulsants, and 6 for all antidepressants. As adverse data were pooled from both diabetic and postherpetic neuralgia studies, methodological factors and heterogenicity in these data may limit the validity and robustness of these ratios. The spectrum of the pain and short study duration tend to underestimate the treatment effect, whereas the small sample size of the studies overestimate the treatment effect.

The above evidence suggests that gabapentin is as efficacious at treating neuropathic pain with no significant difference in minor adverse effects and a low propensity for serious adverse effects compared with other anticonvulsants and antidepressants. Therefore, gabapentin is a useful agent in the multimodal approach in the management of neuropathic pain.

Adverse Reactions in Pooled Placebo-Controlled Trials in Postherpetic Neuralgia

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

Postherpetic Neuralgia

The most common adverse reactions associated with the use of NEURONTIN in adults, not seen at an equivalent frequency among placebo-treated patients, were dizziness, somnolence, and peripheral edema.

In the 2 controlled trials in postherpetic neuralgia, 16% of the 336 patients who received NEURONTIN and 9% of the 227 patients who received placebo discontinued treatment because of an adverse reaction. The adverse reactions that most frequently led to withdrawal in NEURONTIN-treated patients were dizziness, somnolence, and nausea.

Following table lists adverse reactions that occurred in at least 1% of NEURONTIN-treated patients with postherpetic neuralgia participating in placebo-controlled trials and that were numerically more frequent in the NEURONTIN group than in the placebo group.

TABLE 3. Adverse Reactions in Pooled Placebo-Controlled Trials in Postherpetic Neuralgia
NEURONTIN
N=336
%
Placebo
N=227
%
Reported as blurred vision
Body as a Whole
  Asthenia 6 5
  Infection 5 4
  Accidental injury 3 1
Digestive System
  Diarrhea 6 3
  Dry mouth 5 1
  Constipation 4 2
  Nausea 4 3
  Vomiting 3 2
Metabolic and Nutritional Disorders
  Peripheral edema 8 2
  Weight gain 2 0
  Hyperglycemia 1 0
Nervous System
  Dizziness 28 8
  Somnolence 21 5
  Ataxia 3 0
  Abnormal thinking 3 0
  Abnormal gait 2 0
  Incoordination 2 0
Respiratory System
  Pharyngitis 1 0
Special Senses
  Amblyopia 3 1
  Conjunctivitis 1 0
  Diplopia 1 0
  Otitis media 1 0

Other reactions in more than 1% of patients but equally or more frequent in the placebo group included pain, tremor, neuralgia, back pain, dyspepsia, dyspnea, and flu syndrome.

There were no clinically important differences between men and women in the types and incidence of adverse reactions. Because there were few patients whose race was reported as other than white, there are insufficient data to support a statement regarding the distribution of adverse reactions by race.

 

Migraine Headache and Tension Headache Symptoms

A migraine is a severe headache usually followed by symptoms including nausea and vomiting. This would disable you in a few hours or maybe even days. The level at which this happens or even just its frequency varies.

Migraine
Migraine

A recent study shows that women have problems with migraines much more than men. Although its exact cause is unknown, birth control devices happen to be one of many culprits.

A good example ofsuch a birth control device is the oral contraceptives. It is because its ingredients alter the woman’s hormonal level and causes the migraine. The causecertainly is too much estrogen which is certainly put into what is already naturally produced by the body.

Besides migraine, oral contraceptives may cause medical abnormalities from uterine fibroids to breast cancer.

Sometimes, the migraine attack may occur before or after taking the oral contraceptive. If this happens regularly, you are advised to try another method of birth control. This could be avoided though if you take it with food or milk. You should take this at the same time daily and stick with the prescribed dosage that was given to you.

Women over the age of 35 and experience migraines as a result of using birth control tablets and other devices are at risk of getting a stroke. This is another reason why some institutions strongly advice females to use another thing if they don’t want to get pregnant.

Those who are diabetic, have high cholesterol levels and blood pressure are advised not to take oral contraceptives.

But there is hope. One of the newest oral contraceptives to date is Seasonal. This tablet was introduced into the market in 2003 and since it makes females only experience a period four times in one year, this means fewer headaches for migraine sufferers.

But this oral contraceptive may not work for everyone.

In case you suffer migraines due to neurological problems, this won’t do any good and you will have to find another birth control device.

Women may still choose to use oral contraceptives.This really is only after they are examined by the doctor and if everything looks good, he or she will prescribe a lower dose of oral contraceptives. Talking to your physician may even prevent a full blown migraine from happening since there’s really no permanent solution to stop this from happening.

But you’ll find some women who experience migraines even before they start using oral contraceptives. In fact, the frequency didn’t increase or decrease once they were around the tablet but complained that the severity of the migraine got worse.

The severity of the migraine will also not go away overnight after you quit using oral contraceptives. Studies show that it will have a few months to your hormonal levels to normalize and only then will you have the ability to see an improvement.

Despite that, migraines will still happen and you will not blame it only on the tablet but due to other factors such as the food you eat, stress at home or in the office, other medications that you may be taking, physical factors and changes in the environment.

So although there is a direct link between oral contraceptives and migraine, you cannot say that it is the only reason why women suffer from it more than men.

How to can you get rid of migraine All kinds of Headache?

How to can you get rid of migraine All kinds of Headache?


I have used excedrin migraine before and it works pretty good but is there anything else i can try?

Best answer:

Answer by ♀♀LSBN
See your MD about it, even if you need to go to the ER. They will prescribe you something, and maybe have you meet with a neurologist. Exedrine won’t do anything for it. My wife has BAD migraines. She will actually vomit and pass out! Hers get really bad. She goes into the hospital and the MD pretty often. She is on a drug for migraines called Maxalt. You can ask your MD about that, or ask about Topomax or Imitrex. She does NOT use them anymore because they made her feel bad and she is now taking the Maxalt. But your own MD can find a medicine that your body can handle… And you might need an anti-nausea medicine like Reglan if you get sick from the migraines. even though one drug makes you sick, your MD can find one that might help better. My wife also uses that. She lays down with an ice pack after she takes her meds…Some people don’t find anything that really works. Certain foods can trigger it like nuts, peanut butter, pork, spicy food like pepperoni… Also, hormonal things including a menstrual cycle can trigger migraines. I don’t recommend scented things or aromatherapy because migraines can worsen or be triggered by scented things or strong-smelling things. Cleaning supplies, chemicals, perfumes, bleaches… They can be bad for a migraine, and so is bright lights, t.v. screens, computer screens, noises… Migraine Headaches can be affected by what is affecting the senses. A dark, quiet room is best to lay down in. Please see your doctor and good luck.

What do you think? Answer below!

Dangerous Migraine Headache and Tension Headaches

This months topic will address dangerous headaches. To keep this in perspective, most headaches are NOT dangerous. In fact, tension-type headaches and migraines are very common and remain the focus of most health care providers and patients who suffer from headaches. With that said, its important to discuss the signs and symptoms that might help all of us differentiate between headaches that are safe versus those which are not safe.

The most important factor to consider is when the typical headache is suddenly different. Some of these different symptoms may include slurred speech, difficulty communicating or formulating thought, seizures, fainting or loss of consciousness (even for a few seconds), memory lapses, double or blurred vision, profound dizziness, numbness in the face or half of the body, an alarm should sound off telling you to get this checked ASAP as these symptoms, when they deviate from the norm may be indicative of a more serious condition. This can be challenging as seizures are often related to migraines and might be a common symptom of a migraine headache for some migraine sufferers.

Signs of a dangerous headache include:

1.A headache that starts suddenly, especially if it’s of a severe degree.
2.Headaches that start later in life, especially after the age of 50.
3.A change in the quality of headaches.
4.Visual changes, including double vision or loss of vision.
5.Weakness, numbness, or any other neurological symptoms.
6.Fevers especially of rapid onset.
7.Change in mental status including sleepiness, hallucinations, speech changes or confusion.
8.Weight loss.

If there is ever ANY doubt about a dangerous headache, your physician should be contacted.
Typically, the migraine patient will notice a fairly consistent set of symptoms and even though the headaches can vary in intensity, the sequence of events is fairly consistent. Dangerous headaches are the ones that deviate significantly from that migraine sufferers norm. For example, suppose a patients typical migraine is: aura (bright, flashy lights in the visual field or, a strange odor precedes the migraine about 30 min. before the headache strikes), followed by a gradually increasing pain in half of the head which worsens to a point of nausea and sometimes vomiting if something isnt done to stop it (such as a las vegas chiropractic adjustment and/or some form of medication). If this is that patients usual, IF any of the 8 items previously listed above accompany the headache, it should be further evaluated often requiring an EEG (electroencephalogram) and/or MRI (Magnetic Resonant Image). The EEG will test for any electrical signal changes in the brain and the MRI will show space occupying structures such as tumors, bleeding, infection, aneurism, and if performed with a contrast agents, arterial malformations (that is, abnormal networks of blood vessels).