Analgesic overuse headache

Recently I saw a patient in the hospital who had complaint of constant severe daily headaches. She was a 34-year-old otherwise healthy African American woman who first developed headaches at the age of 15. At that time she used to get throbbing hemicranial (one half of the head) headaches which were accompanied by nausea. At times she used to throw up if the headache was particularly bad. During the headache episode she complained of light sensitivity (bright lights bothered her, we refer to this as photophobia) perferring to lie in a quiet dark room. Sleep usually aborted her headache attack. She was correctly diagnosed as suffering from common migraine (this is migraine which is not associated with aura) and treated with Inderal (propanolol-a beta blocker). Later she started using Imitrex (a triptan) whenever she had an acute migraine attack. Around the age of 18, she developed pelvic inflammatory disease for which she started using ibuprofen.

At the time of her current presentation, she said her headache character had changed. Now instead of having episodic migraine attacks, she had a headache “all the time”. She was taking 4-6 pills of ibuprofen a day and 8 to 10 Imitrex pills a month.

This brings us to the topic under discussion “analgesic overuse headaches” also at times referred to as “medication overuse headaches”. Research has shown that about 1% of the general population experiences medication overuse headache and the condition is thought to occur due to an interaction between a therapeutic agent (in this case an analgesic) used excessively by a suspectible patient.

The overuse of anti-migraine drugs and analgesics gives rise to a mixed picture of migraine-type and tension-type headaches that occur at least 15 days a month. Patients start taking more and more analgesics to treat the headache and this sets up a vicious cycle of headache-analgesic-headache-analgesic.

Chronic daily headaches due to overuse of analgesics are particularly difficut to treat. Analgesics are discontinued (some patients of course have worsening of their headache during this time). To keep headaches under check during this time (when the analgesics have been discontinued), the doctor may prescribe a low dose tricyclic antidepressant such as Elavil (amitriptyline). The headache usually resolves or reverts to its previous pattern within two months after discontinuation of the drug (analgesic).

Concussions-let us talk about it

Boxing picLately the topic of concussion is in the news again. Concussions are been increasingly recognized both on and off sports fields. A concussion may be defined as any traumatic brain injury (usually mild) that disrupts brain function. A point to emphasize here is that loss of consciousness is not mandatory for a concussion to occur. Let me explain this with the aid of an example from the sport of boxing. As a ringside physician I sometimes witness a knockout (KO). In a sudden dramatic KO the boxer falls to the canvas and is unable to rise to his feet before the count of 10. In most KOs it is easily apparent that the boxer has also suffered a concussion-he is rendered unconscious (sometimes only for a very short time) and when examined in the ring is frequently confused and disoriented (may not recall that he was knocked out, does not recall which round it is or the name of the arena). In these circumstances a concussion is easy to identify. There are though instances where the boxer may be struck by a ferocious blow such as a hook but he does not fall to the canvas nor does he suffer a loss of consciousness. In these circumstances the concussion is far harder to identify and many a times may be missed by the referee, the boxer’s own corner and even the ringside physician unless the fight is stopped temporarily and the boxer is assessed. Some people refer to these as sub-concussive injuries/blows.

Current scientific data indicates that multiple concussions are not good for the brain and there is concern (some degree of evidence but not definite proof) that it leads to a progressive degenerative disease of the brain called chronic traumatic encephalopathy (CTE) for which currently there is no cure. As prevention is always better than cure, hence the thrust that concussions especially on the sports field be identified in a timely and accurate fashion and athletes be rested (removed from play) till they are asymptomatic.

Nitin K Sethi, MD

The Poor Me Syndrome-Social media networking sites like Facebook and their adverse neurological and psychiatric consequences

The Poor Me Syndrome-Social media networking sites like Facebook and their adverse neurological and psychiatric consequences

Nitin K Sethi, Prahlad K Sethi

The spread and reach of the Internet has heralded a social media revolution in its wake. Social media are a group of Internet-based applications (networking websites, blogs, microblogs, content communities, virtual game worlds) that allow creation and exchange of user-generated content. The use of social media networking websites like Facebook, Twitter and LinkedIn has increased exponentially. In 2014 the total number of monthly active Facebook users was reported to be 1,310,000,000 and total number of minutes spent on Facebook per month was 640,000,000. Forty eight percent of Facebook users log in every day and an equal percentage of users between the ages of 18-34 reportedly check Facebook on waking up. 1We are today more connected to each other than ever before. How we communicate with each other, exchange and share information has undergone a pervasive change. Gone are the days when one kept in touch with family and a few close friends either via postal mail (nowadays referred to as snail mail or smail-yes smail was slow but dependable) or via the invention of Alexander Graham Bell (collect call anyone?). Today’s generation has e-mail, cellphones and cellphone apps. We prefer to text rather than call someone in person, e-mail rather than put pen to paper.

A year ago a 28-year-old young lady consulted me for her seizure disorder. At the time of her presentation; she was on 4 anticonvulsant medications, seizures were well controlled but she was experiencing cognitive side-effects and fatigue. Over the ensuing months under close observation, I began to taper her off one anticonvulsant. Her seizure control remained stable and she felt better. All was going well till one day I received a frantic call from her mother. My patient had attempted suicide by overdosing on her anticonvulsants. She was rushed to a local hospital and later transferred to my hospital where she remained in the intensive care unit for 10 days. As her condition stabilized, she was transferred to the neurology floor and later discharged to a rehab facility. I had the opportunity to speak to her mother recently and asked her the reason why her daughter had attempted suicide. Her attempted suicide it turned out was neither related to her seizure disorder nor her anticonvulsants. Rather she fell a victim to the poor me syndrome. Two of her friends on Facebook had changed their status from single to married and one had uploaded pictures frolicking in the sun with her new beau. Seeing those updates had made my patient feel that life as it was for her was not worth living.

The poor me syndrome is likely an under recognized and under reported consequence of social media networking sites like Facebook. We are increasingly conscious about our online persona and how we reflect that to others. So happy memories and status changes are more likely to be uploaded and updated than times of sadness and struggle. In the days of yore before Facebook was born we knew little what our friends were up to in their lives- who were getting married, who had a new girlfriend or had purchased an awesome house by the beach. Ignorance as they say is indeed bliss for what we did not know did not affect us. Now though; a happy post by one of your friend risks creating sadness and feelings of hopelessness in you.

References

1. Facebook statistics. http://www.statisticbrain.com/facebook-statistics/2014.

Medical, legal and ethical issues surrounding brain death-the physician’s perspective

Medical, legal and ethical issues surrounding brain death-the physician’s perspective

 

Nitin K Sethi1, Prahlad K Sethi2

 

1New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY (U.S.A.)

2Department of Neurology, Sir Ganga Ram Hospital, New Delhi India

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Consider this scenario. A-46-year-old lady suffers an out of hospital cardiac arrest. Cardiopulmonary resuscitation is initiated on the scene by a passerby and later by emergency medical services personnel and return of spontaneous circulation is documented in 30 minutes. After arrival in the hospital hypothermia protocol is instituted. Five days later she remains comatosed and neurological examination is consistent with brain death. Orders are given for medication and ventilatory support to be withdrawn but family refuses saying that she is not dead as long as her heart is still beating. An ethics consultation with the family fails to change their beliefs about brain death leading to a standoff between family and the medical team. What are the clinician’s medical, legal and ethical responsibilities in such cases, not just to the patient but also to the grieving family and the larger society?

Death may be defined as the end of life; the total and permanent cessation of all vital functions of an organism. But this simple definition of death is imbued with strongly held social, cultural and religious beliefs of the patient, the family and our society. Different religions view death and afterlife differently. Hinduism and Buddhism believe in the doctrine of reincarnation. Based on one’s karma either one attains “nirvana” never to be born again and to be finally free of the death/rebirth cycle (moksha)or following death the “atma” (soul) inhabits a new “chola” (body). This is against the Christian held belief of either going to heaven or hell after death. So there exists religious objections to the diagnosis of brain death and in some religions death is thought to have occurred when the heart stops beating. This cardiac definition of death remains far simple to understand by the public at large as compared to brain death. It is readily accepted by family members allowing the process of mourning to begin on the departure of a loved one. Brain death on the other hand is not so readily accepted by family members. How can their loved one be dead when they can still feel, hear and see (on the cardiac monitor) a reassuring heart beat? Terms like apnea test positive, absent brainstem reflexes and flat electroencephalogram make little sense. How can the doctors be so sure that their daughter or son shall never regain consciousness again? Questions like these place a tremendous burden on the family when they are approached for permission to discontinue ventilation. The symbolism of a beating heart slowly flat lining on the cardiac monitor after discontinuation of ventilation is not lost on them. 

From a medical and legal perspective brain death is now a well defined entity. After brain death is confirmed, the law allows (and protects) physicians to discontinue medication and ventilatory support. In many states in the United States and in countries around the world, physicians are not mandated to consult the family prior to withdrawing ventilation though it is recommended that they should. So at least for clinicians there is now little to no ambiguity when it comes to medical (brain death testing is standardized though there remains practice variability in brain death determination among different countries of the world or even among different academic centers in the same country) and legal issues surrounding brain death. Ethical issues surrounding brain death though continue to confront us. Confirmation of brain death makes it obligatory for clinicians to cease all treatment but what if the family refuses to accept the diagnosis. Should we refuse to treat further (after all the patient is dead) or should we continue to treat the dead patient in deference to the family’s wishes? What if we have another alive but critically ill patient who needs that intensive care bed or the ventilator? To who we owe our greatest responsibility-the dead patient, the grieving family or the living critically ill patient who shall die if he does not get care? What to do when brain death is determined in a pregnant woman but whose fetus still has a heartbeat? 1Do we cease treatment (after all the patient is dead) or do we continue to maintain ventilation in this dead patient until the fetus is viable outside the womb? We also have to contend with ethical issues surrounding harvesting of organs from a brain dead patient to extend the life of others. Again to whom we owe greater responsibility-the brain dead patient, the grieving family or the patient in desperate need of that organ?

Determination of brain death raises complex medical, legal and ethical dilemmas for clinicians highlighting the need for medical ethics education during residency training.

 

References

 

  1. Gostin LO. Legal and ethical responsibilities following brain death. JAMA 2014 Jan 24 [Epub ahead of print]

 

 

 

Task specific focal dystonia and dystonic tremor-a question and an answer

A question from one of the readers of my blog. Thank you Melissa and I hope this helps.

 

Question:

 

For a couple years now I have noticed that I have a tremor in my right hand that only acts up when the hand is still or holding something. It shakes really bad and I can stop it when I notice it. It effects my photography and sometimes when I am eating. In motion the tremor stops. I have asked my doctor and he said it is a benign tremor and not to worry about it.. should I be concerned?

 

Answer:

 

Task specific focal dystonia is a not so uncommonly encountered movement disorder. As the name suggests the dystonia occurs or is most prominent only during a specific task. What is dystonia?  Dystonia is a movement disorder characterized by sustained muscle contractions which cause twisting and repetitive movements or abnormal postures. It can affect different parts of the body and be generalized or focal (for example just affecting one hand). There are many causes of dystonia. Task specific focal dystonia is a special type of dystonia which becomes apparent and interferes with the performance of specific tasks such as playing a musical instrument (at times seen in professional violin, piano and guitar players in which it can be career ending at times!), playing a specific sport or while writing (writer’s cramp).

While I do not know if that is what plagues you Melissa, my advice would be to discuss about task specific focal dystonia with your physician or see a neurologist. It is possible that while holding the camera the dystonia becomes apparent and then when you try to grip the camera even more firmly the tremor (dystonic tremor) becomes apparent. I do have a few simple suggestions which may help you:

–try holding the camera in a different way-aka change your/the grip of the camera

–do not grip the camera too hard, hold it lightly.

–use something to support the camera such as a camera stand.

–when you write use a pen/pencil with a thick/broad grip and again do not grip the pen/pencil too hard. Grip it lightly between your thumb and index finger.

 

Nitin K Sethi, MD