Book Notes: Pain Free 1-2-3
Chapter 7: It's Not All in Your Head: Treating Headaches and Facial Pain
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Finding Relief from Tension Headaches
Getting Rid of Migraines
Other Common Severe Headaches
In one study comparing Elavil® 25 mg at bedtime with Remeron 30 mg at bedtime, both groups had less headaches but the Remeron® group had fewer side effects.4 Both of these medications are likely to be more effective for tension headaches than Paxil 40 mg daily, which had only a mild effect.5
In one study of 30 patients with moderate or severe migraine attacks, half received 1 g of magnesium sulfate IV over 15 minutes and the other half placebo. Those in the placebo group who were not better at a one half-hour were then treated with the magnesium. Immediately after treatment, at 30 minutes, and at 2 hours, 86 percent in the magnesium group were pain-free with the other 14 percent showing a reduction in pain. Associated symptoms such as nausea, light sensitivity, and irritability also resolved, and none of the patients in the magnesium group had a recurrence of pain within 24 hours. In the placebo group, no patient became pain free, and only one had a reduction in pain. When patients in the placebo group were later given the magnesium, responses were similar to subjects in the other magnesium treated group. Mild side effects, which are a normal effect of magnesium working to open blood vessels, such as a burning sensation in the face and neck, flushing, and a drop in blood pressure of 5 to 10 mm systolic occurred in 86 percent of the patients. None of these side effects was serious, and no patient had to discontinue the treatment.13 These results were similar to those in previous reports.14 – 15
Fentanyl lollipops (ACTIQ) should be intermittently sucked on, not chewed or swallowed. In between being sucked on, the lollipop should be left between the cheek and lower gum. Time the sucking so that it takes approximately 15 minutes for the medication to be absorbed into your cheek. This makes it more effective. ACTIQ comes in six strengths (200 to 1600 mcg). It begins to work within 5 to 10 minutes, with pain relief lasting approximately 3 hours. Its effectiveness is similar to 2 to 16 mg of intravenous morphine. The most commonly used doses are 400 and 800 micrograms. Because these medications are only approved by the FDA for use in patients who are on chronic narcotics, it is reasonable to have you (if you are not already on chronic narcotic pain medications) take the first dose in a doctor’s office to make sure that it does not cause a dangerous level of sedation. Like other narcotics, this medication can be highly habituating. Because of this, it should only be used as a rescue medication when other medications have failed. Once you have tried the 200 and 400 mcg doses and know that they are not too sedating, begin with a 400 micrograms dose over 15 minutes. If adequate pain relief is not achieved 10 minutes later (i.e. 25 minutes after beginning the first lollipop), use another 200 or 400 mcg unit every 25 minutes until adequate pain control is achieved or you reach 1200 micrograms. The average dose needed is 800 micrograms.
In one study using this approach, all 28 of the patients in the study were able to avoid having to go to the emergency room, with 27 of the 28 patients routinely getting significant relief from pain (decreasing to a “mild” level). The medication was well tolerated with the main side effect being nausea in 18 percent of patients. A few patients had itching that was easily relieved by Benadryl®. Side effects were much less than normally experienced with the usual “rescue medication” (Demerol®).16
Another form of dental pain is “burning mouth syndrome.” This syndrome is characterized by chronic pain on the tongue and sometimes the anterior palate and lips without any visible lesions. It is most common in postmenopausal women and has characteristics suggestive of neuropathic pain. Lipoic acid is an antioxidant that has been shown to be beneficial for diabetic neuropathy. Another study showed that it was also helpful in burning mouth syndrome. In a study of 60 patients, half received 200 mg of lipoic acid 3 times a day and the other half a placebo for 2 to 5 months. Ninety-seven percent of the patients improved versus 40 percent of those in the placebo group. 13 percent had complete resolution of their pain and another 74 percent had “decided improvement,” whereas none of the placebo patients had this level of improvement. Almost all of the patients showed some improvement by 2 months with 73 percent still showing benefit at the end of 12 months despite having stopped the treatment.41 With burning mouth caused by cancer treatment (called mucositis), using a ketamine mouth rinse (from compounding pharmacists) can help.
