Pain and painkillers

Pain and painkillers

Many migraineurs can effectively manage their condition with products bought over the counter in a pharmacy or supermarket. There are numerous products available: Products containing aspirin Aspirin has analgesic and anti-inflammatory properties, which can be effective in the treatment of migraine and other headaches, but is not suitable for all people. Those whose migraine includes nausea and vomiting might be advised to avoid aspirin because of the possibility of gastric irritation. People with a present or past peptic ulcer should not take aspirin nor should those who are aspirin-sensitive. Asthmatics are especially liable to such sensitivity - it is estimated that 4% of asthmatics are affected. Symptoms of aspirin sensitivity include wheezing and broncho-constriction, and also skin rashes. Cross-sensitivity between aspirin and ibuprofen has been reported. The interaction between aspirin and anti-coagulants is well known, and the two should only be taken together under medical supervision. Interestingly, there is evidence that aspirin may be effective in the prevention of migraine. Doses of 300mg on alternate days or 75mg daily are normally suggested. The widespread use of low dose daily aspirin for patients who suffer angina or who have had a heart attack has resulted in an increase of products containing 75mg of aspirin. This is far too low a dose for the acute treatment of migraine. Check the labels or ask the advice of the pharmacist to ensure that you purchase 300mg tablets. At least two such tablets (i.e. 600mg) are required for a therapeutic dose. Enteric coated aspirin tablets, which make the product easier to swallow, are also available. These take longer to work and are unsuitable for migraineurs, who should preferably opt for a soluble form. Aspirin products are not recommended for children under 16 years. Products containing ibuprofen (Non-Steroidal Anti-Inflammatory Drug - NSAlD) Ibuprofen can also be effective in the treatment of migraine. The possibility of gastric side effects should be considered, although the incidence of such effects is likely to be lower than with aspirin. Asthmatics are probably best advised to avoid ibuprofen because of the possibility of sensitivity. Ibuprofen is best avoided by anyone taking anti-coagulants and should not be recommended for anyone who has or has had a peptic ulcer. The recommended dosage is 2 x 200mg tablets. Ibuprofen is now available in the new melt formulation which dissolves in the mouth without water and is, therefore, convenient to take at any time. Some sustained release products containing ibuprofen 300mg are now available and these may be unsuitable for migraineurs as fast action is needed.

Products containing paracetamol Migraine is believed to be a sterile inflammatory process so anti-inflammatory drugs, such as aspirin and ibuprofen will probably be more effective. However, paracetamol is preferred by some people for the treatment of migraine and has the benefit of being free from gastro-intestinal side effects. A dose of less than 1g (usually 2 tablets) of paracetamol is unlikely to be effective in treating a migraine attack. Many products contain sub-therapeutic doses of paracetamol as there is concern about its overdose potential; purchasing a sub-therapeutic dose is a waste of money. Fears of overdose have resulted in legislation restricting the sale of paracetamol and aspirin in supermarkets to packs of 16 and 32 in pharmacies, although pharmacies can, at their discretion, supply up to 100. Larger quantities now require a doctor s prescription. Purchasing paracetamol in supermarket quantities of 16 tablets is an expensive process but requests for more tablets at a pharmacy may result in interrogation by a pharmacist. It is therefore advisable to make yourself known to your local pharmacy as a migraineur to enable the pharmacist to advise on the most suitable treatment for you as an individual. Individuals should always be reminded that the maximum adult dose of paracetamol containing products is 4g daily, i.e. eight 500mg tablets. Although this may appear common sense, it should be remembered that anyone in considerable pain may be tempted to increase the dose. Patients who are concerned about the possibility of overdose may purchase a product which also contains the antidote (methionine), such as Paradote. Such products are more expensive and the patient runs the risk of taking two drugs when only one is necessary. However, the evidence is that these products are safe and can be used with confidence, if concern of overdose is an issue. Combination products containing codeine There are a lot of analgesic products containing aspirin, paracetamol and / or ibuprofen combined with codeine. The British National Formulary says that such products rarely have advantages over single analgesics and that they should not be used. However, while it is true that scientific evidence does not indicate improved efficacy from combination products, some people find that such products work better for them. There is a high placebo response in analgesic therapy and patients beliefs will influence the outcome of treatment. From the pharmacological viewpoint, a dose of at least 15mg codeine is required for painkilling effect and products purchased over the counter seldom contain this amount. Constipation is a possible side effect with codeine, and this may be a problem in the elderly who tend to be constipated anyway and who may also be taking other medication which has a constipating effect. Some of the proprietary combinations are available in dispersible or soluble forms which will act quickly and thus may offer an advantage. Codeine is believed to be the biggest culprit in the development of medication overuse headache, so should be taken with caution.

Combination products containing caffeine It is believed that a small amount of caffeine enables the body to absorb paracetamol more easily. It is worth noting that caffeine, included in some combination painkillers, can be an irritant to the stomach, an undesirable effect when nausea and vomiting are a problem. Caffeine also has a mood lifting effect which may be undesirable if you intend to rest or sleep. However, if you need to struggle home or carry on working, a little caffeine may be just what you need. You will get as much or more caffeine by drinking a cup of coffee with your painkillers as you would by taking more expensive combination products. Combination products containing anti-histamine Migraleve combines the anti-histamine buclizine, which has anti-sickness properties, with paracetamol and codeine. The pink tablets contain all three ingredients and are designed to be taken early in the migraine attack; the yellow tablets contain paracetamol and codeine. The product is worth a try where nausea and vomiting are associated with a migraine headache. Migralift is a similar product. The anti-histamines doxylamine and diphenhydramine are found in some over the counter products in combination with paracetamol, codeine and caffeine. The sedative and relaxant effects of the anti-histamine may be particularly useful in cases of tension headaches and also in other types of pain. As with all products containing the older type of anti-histamines, drowsiness may occur and the usual rules must be observed about driving or operating machinery. Combination products containing isometheptene Isometheptene is a vasoconstrictor; it is currently available combined with paracetamol in only one over the counter product, Midrid, and is available from pharmacies only. There is some evidence of efficacy for this combination. It should NEVER be taken with any other products containing paracetamol. If over the counter products do not significantly relieve your migraine symptoms, there are numerous effective treatments available on prescription. Consult your GP to confirm the diagnosis and discuss treatment options. What is in your painkiller? Painkillers should have information about what they contain printed on the box or packet. If this information is missing, always ask the pharmacist what the tablets contain and ask him to write it down for you. It s easy to overdose on ingredients if you don t know what is in the products you are taking. In addition to branded painkillers, there are generic and own brand versions (e.g. pharmacy chains and supermarkets) of many of these products which are usually cheaper than the brand names. When you find a product which suits you, ask your pharmacist for the cheapest version of it. This could save you considerable sums of money whilst still bringing effective relief.

Products suitable for children Painkillers for children are available in liquid form and melt type, as well as tablets. Always check the label on the bottle to ascertain that the product is safe and suitable for the specific age of the child and the appropriate dosage. If you have any doubts or concerns, please consult your pharmacist. Children should never be given medication prescribed for adults unless specifically recommended by your doctor. Timing of painkillers Because stomach emptying slows down once a migraine attack is established (a condition known as gastric stasis), any painkillers should be taken at the earliest stage to try to ensure that the drug reaches the intestine, where most of it is absorbed. Soluble products work more quickly than standard formulations and are worth consideration. If you do not have any soluble painkillers available, try taking ordinary tablets with fizzy water or a sweet fizzy drink. If you do not have immediate access to a drink, take your tablets anyway, they have more chance of working at an early stage than if you delay until a drink is available. It is important to take your painkillers as early as possible during an attack, preferably at the first warning sign. It is easy to delay in the hope that the attack will not develop but this can result in hours of needless suffering. Keep your painkillers to hand at all times. Many migraineurs keep supplies in various locations e.g. in their handbag, in the car, at work etc. so that they always have a supply readily available. Medication overuse headache ( painkiller headache) It has recently been established that too many painkillers, taken regularly to treat headache, can cause extra headaches in susceptible people. Regularly taking painkillers on more than 2 days a week can lead to chronic daily headache which is defined as headache on 15 days or more per month, every month. It is estimated that 3-4% of people in the UK suffer from this condition some of whom have a headache every day. For further information about medication overuse headache, please visit www.migraine.org.uk/moh. Duplication of treatments The possibility of duplication of treatment must be borne in mind. Many people are unaware that medicine they may buy over the counter may contain the same ingredients as the one they obtain on prescription. Thus, patients taking non-steroidal anti-inflammatory agents may request ibuprofen over the counter. People taking codydramol, cocodamol or coproxamol prescribed by their doctor may be unaware that their medicine contains paracetamol and so overdose is possible if other analgesics containing paracetamol bought over the counter are taken alongside them.

Enlist the help of your pharmacist Although it is very convenient to pick up a supply of painkillers with your weekly shopping, the advice available in a pharmacy is of considerably more help than that afforded by the check out assistant in the supermarket. The pharmacist has training in the actions and uses of drugs which is at least equal to that of a GP, and the pharmacy staff are obliged by the Pharmaceutical Society to have undergone an approved training in medicines. If you register with a local pharmacist and are also taking other medication prescribed by your doctor, they will keep a computerised record of this and advise you of any potential interactions with drugs that you may purchase over the counter. If you have any concerns about any medication either prescribed by your doctor or purchased over the counter, please consult your GP or pharmacist before taking it. Painkillers and gastric stasis Many people believe that what they need to treat migraine attacks is a stronger painkiller. However, what they really need may be something that will help the simple painkillers to work more efficiently. Our digestive system slows its normal activity during a migraine attack, a condition known as gastric stasis, when nothing is absorbed into the system and therefore no benefit is gained from any tablets that have been swallowed. If medication is taken after stasis has commenced, the drugs will remain locked in the stomach as will any further doses taken during the course of the attack. Therefore, even though the recommended dosage intervals have been observed, theoretically there is still the risk of overdose when normal functioning resumes and two or more doses are absorbed simultaneously. Metaclopramide and domperidone, two drugs normally prescribed for nausea and vomiting, can make the digestive system work normally again, allowing painkillers to get to work. These drugs can be taken either 15 minutes before or alongside your usual painkiller early on in a migraine for best results. The golden rule is recognise your warning signs and take painkillers before the pain starts; add one of the drugs mentioned above and you have a very good chance of preventing your migraine from developing. Both metaclopramide and domperidone are available on prescription. Domperidone is also available as a suppository, useful if vomiting has already started. Products containing painkillers and anti-sickness drugs are available on prescription and include Paramax, Migramax and Domperamol. Products available over the counter for the prevention of nausea and vomiting are Buccastem M and Motilium. Buccastem M is held between the lip and the gum where it slowly dissolves.

What is pain? The International Association for the Study of Pain (IASP) defines pain as: an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. In arriving at this definition, the IASP noted that pain has many dimensions - social, mental and physical - each contributing to the individual s perception of, and reaction to, a pain experience. It also recognised that there are four separate elements to pain as a clinical phenomenon. Firstly, the detection by special nerve receptors of actual tissue damage by injury, temperature mechanical or chemical action which result in the transmission of nerve messages to the central nervous system (CNS). Secondly, the perception of pain when these nerve impulses reach the CNS. Thirdly, suffering which is a mood generated by higher emotional brain centres in response to the pain. Fourthly, outward behaviour to the pain and suffering, such as crying, limping, seeking medical help etc. Understanding these different components can lead to better pain management and the adoption of appropriate treatment. Pain is an experience common to all mankind. It is a subjective experience; what causes severe pain to one person may cause only mild or no discomfort to another. The experience of pain can be influenced by factors, such as fear, anxiety, depression, circumstances, belief and previous experiences of pain. The mechanisms are by no means fully understood. Acute pain is short-term reversible pain which can last from a few seconds to a few hours, days or weeks. Examples of acute pain are toothache, burns, fractures, period pain, post-operative pain, headaches and migraine. Acute pain often initially serves as a warning that something is wrong and leads us to seek the help of a doctor or other healthcare professional. Acute pain can cause the same symptoms as anxiety i.e. faster breathing and sweating. However, much acute pain is selflimiting and healing will take place in its own time, such as after a sprain. For many of these conditions, such as headaches or post-operative pain, benefit is achieved by relieving the discomfort with analgesics (painkillers) while healing takes place. Chronic pain is persistent and intractable and may worsen with time rather than get better. It persists long after the warning function of pain has been outlived and can last from months to years. Acute or everyday pains, such as headaches, sprains and strains, obviously warrant investigation into their cause which is usually very apparent; for example, headaches produced by stress or tension, dental pain resulting from tooth decay or infection, muscular pain from a strain or sprain. These conditions can be self-limiting and therefore will heal themselves. The aim of analgesics is to relieve pain and hence improve the quality of life. They are therefore most useful in the treatment of acute pain, unless analgesics are likely to mask the symptoms of something more serious.

Web: www.migraine.org.uk Factors influencing our feeling of pain Many factors influence the experience of pain besides the nature and severity of an injury. Not only do different people have different perceptions of pain but also the same person may experience pain less or more according to differing circumstances: Anxiety: People who are frightened that they are going to experience pain, for example at the dentist, are likely to feel more pain than those who are calmer. In some cases, anxiety itself can cause pain; it commonly manifests itself in the form of severe headache (tension headache) or stomach pain and abdominal cramps. Depression: If you are feeling miserable, banging your head or stubbing your toe may seem much more painful than usual. On the other hand, for chronic pain sufferers, depression is a consequence of constant pain and also exacerbates it, feeling miserable makes it far harder to cope with any adversity in life. Helplessness: Someone who is incapacitated either by chronic pain or by an injury and is dependent on others may often feel more pain. Feelings of helplessness increase feelings of depression which increase pain, perpetuating a vicious circle. Lack of information: Your ability to withstand pain may be reduced by not knowing the full story about what is the matter with you when you are ill, not understanding the treatment you will be given or whether it is likely to be effective. Expectation: If we believe that a pain is only going to be temporary and will not bother us, we are less likely to feel so much pain. Personality: Studies have shown that introverts, shy and quiet people who prefer their own company, have lower pain thresholds than extroverts, more noisy, outgoing people who thrive on company. However, introverts complain less! Complementary treatments Many people are reluctant to take drugs to alleviate their pain, for a variety of reasons. There are some complementary treatments available to help manage the condition, such as biofeedback, homeopathy, osteopathy, relaxation techniques etc. For further information please visit www.migraine.org.uk/complementary. For further information, advice on migraine management and for updates on the latest migraine research, please contact Migraine Action by calling 0116 275 8317, emailing info@migraine.org.uk, or visiting the charity s website at www.migraine.org.uk. All of our information resources and more are only made possible through donations and by people becoming members of Migraine Action. Visit www.migraine.org.uk/donate to support one of our projects or visit www.migraine.org.uk/join to become a member. With thanks to: Migraine Action would like to thank our Medical Advisory Board for reviewing this information. 4 th Floor, 27 East Street, Leicester. LE1 6NB. Tel: 0116 275 8317 Fax: 0116 254 2023 Email: info@migraine.org.uk Web: www.migraine.org.uk Registered Charity No. 207783 Copyright 2010 Migraine Action This publication provides information only. Migraine Action and its officers can accept no responsibility for any loss, howsoever caused, to any person acting or refraining from action as a result of any material in this publication or information given. Whilst this booklet has been reviewed for accuracy by members of Migraine Action s Medical Advisory Board and other experts, the information does not necessarily reflect the views of individuals. Medical advice should be obtained on any specific matter.