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Cluster Headache Features and Therapeutic Options

Posted on 05. May, 2012 by wisdom.

A review article titled “Cluster Headache: Clinical Features and Therapeutic Options” written by Charly Gaul, Hans-Christoph Diener, and Oliver M. Muller published in Deutsches Ärzteblatt International (vol. 108, issue 33, pages 543-549, 2011) provides an interesting look on new options for those with a chronic refractory cluster headache.

The article discusses how 120,000 people in Germany are affected by cluster headache. The attacks are in the periorbital area on one side and last 90 minutes on average. The attacks often posses a circadian and seasonal rhythm. The author lists the diagnostic criteria for cluster headache as from the International Classification of Headache Disorders (ICHD-II).

First line drugs for treatment include verapamil and cortisione or lithium and topirmate. In addition, short term relief can be obtained by local anesthetics and steroids along the course of the greater occipital nerve.

I have taken verapamil as discussed over at http://www.teethremoval.com/ndph.html and also had lidocaine injected into my occipital nerve as discussed over at http://www.teethremoval.com/occipital_nerve_block.html as treatment strategies after suffering from a 24/7 headache 2 days after having all 4 healthy wisdom teeth removed. I did not have a positive experience with the occipital nerve block which just led to more lasting pain and problems.

Another treatment strategy is inhaling oxygen which I also have experience with. The author also suggests administering lidocaine solution into the nostril which I also have experience with as well.

In those cluster headaches that are refractory to treatment which is defined as a cluster headache that over 24 months has significant impairment’s to the patient’s quality of life and socioeconomic status there is no uniform treatment strategy. Guidelines recommend verapmil of greater than 400 mg, lithium carbonate of greater than 800 mg, topiramate of greater than 100 mg, indomethacin of greater than 150 mg to exclude hemicrania continua, methysergide of greater than 8 mg, and corticosteroids such as prednisolone of greater than 100 mg.

I also did take indomethacin and prednisolone in the earlier stages of my treatment.

The author goes on to discuss newer invasive procedures that are available for severely impacted patients with chronic cluster headaches that are refractory to treatment which includes deep brain stimulation in the hypothalamus (DBS) and bilateral occipital nerve stimulation (ONS).

The author states

“Ablative procedures such as rhizotomy of the root exit zone of the trigeminal nerve or destructive procedures to the Gasserion ganglion have been abandoned because of severe irreversible side effects (anesthesia dolorosa). Stereotactic radiosurgical interventions (gamma knife) have proved effective in a small case series, albeit at the cost of persistent hyposensitization.”

Other possibilities mentioned include spinal cord stimulation (SCS), vagus nerve stimulation (VNS), and stimulation of the sphenopalatine ganglion (SPG) but limited evidence is available for these methods.

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Evidence Base for Oral and Maxillofacial Surgery Journals

Posted on 17. Mar, 2012 by wisdom.

An interesting articled titled “The evidence base for oral and maxillofacial surgery: 10-year analysis of two journals,” appeared in the January 2012 edition of the British Journal of Oral and Maxillofacial Surgery (vol. 50, issue 1, pages 45-48) wirrten by Amandip Sandhu.

The author opens by discussing an editorial in the Lancet in 1996 which discussed how there is a lack of scientific rigor in surgical research.

The author states

“There is a well established hierarchy of levels of evidence, and the medical community considers that meta-analyses and randomised controlled trials (RCTs) are the most scientifically stringent means of investigating the efficacy of one intervention against another. Other grades of evidence (in increasing weakness of level of evidence) are case controlled studies, comparative studies, case series, correlation studies and expert committee reports, and the clinical experiences of respected authorities.”

The author evaluated articles published in both the British Journal of Oral and Maxillofacial Surgery and the International Journal of
Oral and Maxillofacial Surgery between January 1999 and December 2009. The author looked at the abstract of every article and looked at the article in full if the abstract was not sufficient for analysis.

The author looked at 3294 articles and 1 meta-analysis and 68 randomized controlled trials (2%) were present.

The author points out how if one recommends involvement in a randomized controlled trial there must be a uncertainty about the benefit or harm from the intervention. Further using sham surgery as a control has issues.

The author briefly mentions the National Institute for Health and Clinical Excellence (NICE) and a brief discussion of the Cochrane Collaboration is made in which the author states that reviews relevant to oral and maxillofacial surgery consists of weak evidence.

The author than goes on to discuss the Impact Factor and how it should be interpreted with care.

The author states

“The latest [impact factors] IFs for the International Journal and the British Journal (2009) are 1.444 (2008: 1.487), and 1.327 (2008: 0.787), respectively. For comparison, the five medical journals in 2009 with the highest IFs were the New England Journal of Medicine (IF 50.017), the Journal of the American Medical Association (IF 31.171), The Lancet (IF 28.409), Annals of Internal Medicine (IF 17.457), and the British Medical Journal (IF 12.827).”

The author ends by saying

“Although the number of RCTs is comparable with other related specialties, in common with other surgical disciplines more effort is required to carry out better quality, ethical research if we are to provide patients with the best possible evidence for our interventions, given the recognised difficulties in carrying out such research.”

A table with the results of the analysis is presented in the article. A total of 618 of the 1715 (36%) BJOMS articles reviewed and 481 of the 1579 (31%) of the IJOMS articles reviewed consisted of case series which were by far the highest type of papers in the journals.

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Why Bother With Research

Posted on 10. Mar, 2012 by wisdom.

An intriguing article recently appeared in the International Journal of Oral and Maxillofacial Surgery titled “Research – why bother?” (vol. 40, issue 12, page 1346, December 2011) written by G. Dimitroulis.

The article discusses of oral and maxillofacial surgery needs research to make itself known as a professional body and not as just a technical trade. A brief mention is made that dual degree programs place time pressures on trainees at the expense of research.

The author mentions how head and neck surgical oncology is shared by a number of surgical specialties with mutual interest.

The author states

“We cannot rely rely on the research experience of other surgical specialties if we are to secure the respect and trust of our medical and surgical colleagues from other disciplines who also have a mutual interest in head and neck oncology.”

The author goes on to say

“It is only through our diligent efforts to record and analyse our surgical experiences, and making these known to the world through journal publications, that we are able to consolidate our interests in various specialized areas of surgery such as cleft surgery, trauma, surgical oncology and implants and so on.”

The author says that all hospitals with oral and maxillofacial surgery units should strive to at least make the effort to collate data from various clinical audits that could potentially be put together as papers for publication.

The author states

“Regrettably, there are far too many operative procedures devised and promoted in clinical journals by experienced surgeons who have little appreciation of the fundamental importance of good research and evidence-based medicine”

The author is very critical that some are not practicing patience and have too short of a time frame when it comes to research.

The author recommends research interest groups are formed that can help teach and promote the tools and skills required to undertake and communicate research results.

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Perioperative Information for Third Molar (Wisdom Teeth) Removal

Posted on 11. Feb, 2012 by wisdom.

A recent study titled “An Evaluation of Patients’ Knowledge About Perioperative Information for Third Molar Removal,” appears in the Journal of Oral and Maxillofacial Surgery (vol. 70, pages 12 – 18, 2012).

The study attempts to look at what patients know about third molar (wisdom teeth) removal before having surgery performed. The study was conducted by authors in Brazil and Kentucky (United States).

The study explains on being nervous and anxious before having wisdom teeth removed can actually cause a longer surgery, more potential swelling, and even more pain.

Hence there is incentive for the surgeon and the surgical team to help produce a calming environment for patients to help reduce anxiety which can lead to potentially better outcomes.

The study had 67 patients which included 43 female and 24 males who had 1 or more wisdom tooth removed. The patients presented to an ambulatory environment between August 2009 and April 2010 in Brazil. One surgeon interviewed each patient and this surgeon was blinded as in did not know about the patient’s past tooth extraction experience(s).

In this study 25 of the patients had previous tooth extraction experience. Most of the wisdom teeth were extracted for orthodontic reasons. Other reasons for the removal of the wisdom teeth included pericoronitis, pain, difficult to clean, caries (cavities), malocclusion, periodontitis, and in 4% of the cases as a preventative measure.

Discussions in the study mention other studies which discuss how many patients like to have a consultation on a separate day than on the day of the surgery. A trustworthy and professional relationship is important to be formed between patient and doctor.

The study showed that patients who had previous extraction experience showed more interest and knowledge about the possibility of a preoperative medication taken before surgery.

Even so, the study also showed that surgeons should not assume that those who have previous extraction experience have greater knowledge about dental extractions.

The second to last paragraph of the study states:

“Although some referrers may be able to educate the patient, it is the role of the surgeon to educate the patient and to build up a rapport and engender trust at the first consultation. The referrers may not give the correct information, leading to a case of mixed messages being given to the patient and adding to the confusion and mistrust.”

The study identified that the 2 areas patients have the most misconceptions about include whether or not a medication should be taken preoperatively and what type of hygiene (cleaning) should be done after surgery.

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Medical School Student Costs in the U.S. are Affecting Mental Health

Posted on 24. Dec, 2011 by wisdom.

A research letter titled “U.S. Medical Students’ Health Insurance Coverage for Mental Health and Substance Abuse Treatment” published in the Journal of the American Medical Association  vol. 306, no.9, pages 931-933, in September 7, 2011, and written by Rachel Nardin and et al. discusses how medical students are often sleep-deprived, depressed, and have thoughts of suicide. This can lead to lack of empathy for their patients and contribute to additional medical errors once they graduate. It can also lead to substance abuse. Even so these medical students are not being adequately treated for their psychiatric disorder or substance abuse due to wanting to avoid adding additional costs to their already substantial debt from school.

The study looked at health insurance offered by 115 of the 129 U.S. medical schools between June and December of 2010. It found that the coverage for mental health varies substantially.

J. Wesley Boyd one of the study authors says via an article published on wbur.org titled Study: Cost s keep Med Students From Much-Needed Mental Health Care written by Carey Goldberg and published September 7, 2011, located at http://commonhealth.wbur.org/2011/09/med-students-psych-care/

“Troubled students often resist seeking treatment at the onset of their symptoms, fearing high out-of-pocket costs and an accumulation of more school debt. But with any psychiatric disorder or substance abuse early intervention definitely correlates to better outcomes….mounting debt from long stints at expensive schools weighs very heavily upon the students and most will do anything they can to avoid increasing it…. We need our medical schools to push themselves to provide students with more affordable care. What’s best for the health of our students will result in better physicians and the future wellbeing of their patients.””

I have previously discussed the issue of increasingly out of control costs of college and medical school in the U.S. http://blog.teethremoval.com/astroturfing-and-how-your-thoughts-are-being-manipulated-by-corporate-interests/ and http://blog.teethremoval.com/lets-give-our-kids-a-chance-to-succeed/. Many students graduate after medical school with debts higher than $150,000. Private school debts are naturally higher than those of public schools.  Also see this article http://blog.teethremoval.com/college-conspiracy-and-united-states-hyperinflation/.

Things in the U.K. are very different than in the U.S. with regards to cost. An article titled Patient Safety in the US and UK, Part I: The Doctors written by Bob Watcher and published September 4, 2011, and located at http://community.the-hospitalist.org/2011/09/04/patient-safety-in-the-us-and-uk-part-i-the-doctors/ discusses how in the U.K. medical school students enter a 6 year program right after high school and graduate from their medical school with very little debt. In the U.S. students go to a 4 year college to get an undergraduate degree and then on to a 4 year medical school. With the average student debt of an undergraduate degree of around $27,000 and the average student debt of a medical degree of around $158,000 (depending on the school and if private or public of course)  students in the U.S. can expect a debt of around (if not much more)  $185,000 to become a doctor.

As I have previously discussed on this blog in an earlier post:

“Unfortunately I am beginning to think that the ballooning out of control cost of higher education is a scheme designed by large corporations and special interests so that things such as medical procedures promoted on shaky scientific ground and continuing to lower the definition of various diseases so that more and more drugs can be sold will become more and more the norm since the doctor will be an indentured servant to their debt.”

Additional Sources:

http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/medical-student-section/advocacy-policy/medical-student-debt/background.page?

http://www.npr.org/2011/05/16/136214779/college-student-debt-grows-is-it-worth-it

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