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Reader's Mail: Can Lidocaine Patches Be Cut?

Can Lidocaine Patches Be Cut to Smaller Size?

Q. Though they help with my chronic headache pain, lidocaine patches can be cumbersome to apply. My local pharmacists are in disagreement: One says patches cannot be cut, but the other said I could cut my lidocaine patch to a size more suitable to my needs. Who is correct?

A. As a general rule, medication patches should not be cut or otherwise altered. Cutting the patch could increase the absorption of the drug, which could increase side effects, deplete the patch’s medication too quickly and cause other problems.

Lidocaine patches are, to my knowledge, the only exception to that general rule. A lidocaine patch’s dimensions are approximately four inches by six inches, which is rather large to place on a forehead (the location used by most patients). With a pair of scissors, patients can cut the patch to an appropriate size prior to applying to their forehead or other hairless area. Typically, patches are left on for 12 hours then removed for 12 hours prior to applying another patch.

Richard Wenzel, Pharm.D.
Diamond Headache Clinic
Chicago, IL

New Treatments for Migraine

Q. I am interested in finding out if there is anything new available for migraine treatment. I have had migraines from the age of 38 (when I became menopausal) and am now 60. I am now and have been for many years on beta blockade preventive therapy as I failed to tolerate Imitrex (heart rate of 30) after three successful doses and would be loathe to try any of the chemically related products in that line. I also had an adverse reaction to Topamax (after several successful years, other than some vague short term memory loss, I became grossly paranoid).

My headaches begin usually after excessive stress and fatigue (I’m an RN employed in a nationally known university hospital in the Coronary Care Unit) but can occur anytime. I was recently diagnosed with Wolffe Parkinson White syndrome and had an ablation so I need to be cautious about taking any medication with cardiac side effects. I had borderline hypertension which the beta blockade now renders nonexistent. My average BP is currently 98/’64 to 110/70. My only other medical conditions are hypothyroidism (which is being supplemented) and mild asthma which flares only in the presence of an URTI. In spite of being a vegetarian and having a very healthy lifestyle, I still have migraines at least twice a month, always coexisting with some left arm tingling, sometimes bilateral arm tingling with concurrent nausea and severe left temporal pain that unfailingly lasts three days, even when I take my Fiorinal quickly and, if I am not at work, lie down and rest or sleep. I also use ice packs on my head and avoid bright lights.

A. Thanks for the questions. For acute pain control, you might use Midrin, dosing two caps at the start of a headache and one every 45 minutes for up to three more doses. Liquid ibuprophen can be effective, too, as can the gel cap form of sodium naproxyn. I have not been impressed with the tablet form of either ibuprophen or naproyen, probably due to relatively slow breakdown and absorption in the setting of nausea. A small amount of Fioricet could be combined with the ibuprophen or the naproxyn.

For prevention at a frequency of two per month, I recommend magnesium aspartate, 500 to 1000 mg at night (kidney function needs checking prior to starting this), and/or vitamin B2 (riboflavin) 200 mg twice a day with meals. The magnesium in this formulation is well absorbed and well tolerated. It should not be taken at the same time of the day as iron, calcium or zinc as they will interfere with the absorption of the magnesium. The B2 will turn the urine a bright yellow which is normal for taking in that amount of it. Biofeedback training is great for stress management and can be viewed as a life skill that is always available to you, much like yoga and meditation. A medication for prevention that would not seem to be contraindicated in your case is gaba-pentin, taken at night in doses of up to 900 mg. Finally, for people with migraine, prevention really rests on excellent self care, including a good diet, hydration, rest, exercise and stress management. All the best.

Doug Mann, M.D.
UNC Professor of Neurology
Chapel Hill, NC

Raynaud’s Syndrome and Frequent Migraines

Q. I have recently been diagnosed with Raynaud’s Syndrome. Is there a connection between Raynaud’s Syndrome and frequent migraines headaches, and or the long-term, frequent use of Sumatriptan (10-18 doses of 50 mg. pills per month). Also, I have noted that Raynaud’s is a contraindication for Sumatriptan use. But, what exactly is the risk, if any, for continued use?

I am 44 years old. I experienced headaches as a child, but began having full-blown migraine type headaches in my early 20s. At the time, they were occasional, and did not have a major impact on my quality of life. But in 1992 and then again in 1994, I was involved in auto accidents that did not involve head injury, but did result in “cervical strain” and “whiplash.” The first was a more severe accident, but the second is what triggered the onset of daily, severe headaches and neck pain, beginning two days following the accident. I was not aware of the extent of the damage until a year ago, when I had an MRI that revealed normal brain structures and four herniated cervical discs, with one compressing the C7 nerve root, and another impinging on the spinal cord. Initially, I treated my daily headaches and neck pain with 800 mg doses of Ibuprofen, several times per day, which eventually became ineffective and began to cause chronic gastritis, and rebound issues. In 1997, my doctor prescribed Sumatriptan, which was very effective, and has significantly improved my quality of life. I now experience headaches about 10-18 days per month. The headaches are cyclical, usually occurring in 3-7 day episodes, one of which always occurs prior to or during menstruation. I have noticed that at certain times, I seem to be in a “hypersensitive phase,” where any of my known potential triggers will set off an episode.

A. The first issue which you need to have clarified is what you specifically have. Raynaud’s phenomenon is a vasospastic disorder that may cause discoloration of the fingers and toes. The phenomenon is believed to be the result of vasospasms that decrease blood supply to the respective regions. Emotional stress and cold are classic triggers of the phenomenon. Migraine patients, with their hyper reactive autonomic and general nervous system appear to have this commonly. Many will have cold hands when they have their migraines. They are more likely to have Raynaud’s disease. There is also a more serious form called Raynaud’s syndrome, in which other instigating factors cause this. The syndrome is the more severe of the two types and can lead to gangrene of the fingertips. It is extremely rare for the Disease form to cause this type of complication.

The process regardless of form is characterized by cyclic color changes of the fingers or toes: with cold exposure the blood supply to the fingers or toes is reduced and the skin turns pale and becomes cold and numb. If severe enough then the oxygen supply becomes depleted and the skin turns blue. As it subsides and the blood flow returns the skin first turns red then back to normal. At that time there may be swelling and tingling. Regardless of the type, cold exposure, smoking and caffeine make it worse. If the process is severe and diagnosed as Raynaud’ syndrome a comprehensive examination to look for other diseases that may cause this should be undertaken by a doctor familiar with this disorder. A variety of diseases, drugs, and occupations may cause or contribute to it.

Sumatriptan can precipitate Raynaud’s phenomenon. If the patient has the more common disease form, then it may not prove to be a major impediment to its use but obviously careful evaluation is important here to determine that issue. Those who have the Syndrome form however, have a greater risk of vascular complication to begin with and so the use of a medication in the triptan or ergot family can precipitate a serious event that could result in permanent damage and the loss of a finger or toe.

Appropriate treatment of any underlying causation of the disorder and treatment for this may allow some patients to use the triptans safely.

As to the remainder of your headache history, it is obvious that the you have experienced significant impact from that accident that now has created a raft of issues from increased headache and neck pain to increased migraines to complications of treatment such as the gastritis. Comprehensive management of your headache and other pain problems with medication and non medication approaches, optimal communication between you and your health care provider and appropriate optimization of your general health are all important steps in this process.

Fred Freitag, D.O.
Diamond Headache Clinic
Chicago, IL

New Daily Persistent Headache Is Tricky to Understand and Treat

Q. What is new in the research and treatment of NDPH (New Daily Persistent Headache)?

A. New daily persistent headache is a puzzling thing. For those who aren’t familiar with it, I’ll give a brief description. NDPH is daily headache that starts suddenly and is daily from the outset. Often it happens in people who have never had any sort of headache before. Patients can often name the exact time the headache started. Sometimes they will report having a cold or viral illness when things started. Other times the headaches will start during a period of stress. Still other times, it will seem like the headache truly came out of the blue.

There are a few things that can act very much like NDPH and need to be considered. Sometimes daily headaches can start after even very mild head trauma. This is generally diagnosed as post-traumatic headache, but it often acts similarly and is treated similarly to NDPH. Low cerebrospinal fluid pressure headaches, which usually are much worse when upright than lying down, are not always so clearly positional, and can look similar to NDPH. Finally, medication overuse headache can appear to start suddenly (though it should not be as sudden as NDPH). When medication overuse headache masquerades as NDPH it is likely because the medications were used for something other than headache, such as low back pain.

NDPH is very hard to study in the laboratory, so it’s hard to get basic insights into how it works. While I am speculating, it seems reasonable to assume that some event or series of events sensitizes the trigeminovascular system the network of nerves and blood vessels that transmit pain in the head. But it is hard to understand why such a sensitization would occur so suddenly, without warning.

Also tricky about NDPH is that there is not much consistency in which medications work. This may be because NDPH is actually more than one entity. It is reasonable to try several medications from different drug classes to maximize your chances of success. Your healthcare professional can help with this.

K.C. Brennan, M.D.
David Geffen School of Medicine
UCLA
Los Angeles, CA

Treating Headaches with Magnets

Q. Have you heard about the use of magnets to prevent or treat headaches?

A. A wave of brain hyper excitability followed by a wave of inhibition is called cortical spreading depression (CSD). CSD is thought to occur in those who have migraine with an aura. However, it has also been suggested that CSD may even occur in migraineurs without an aura or in those with migraine without aura. Animal studies suggest that CSD can trigger pain receptors of the membranes which envelope the brain and cause migraine.

Transcranial magnetic stimulation (TMS) is a technique that applies a brief magnetic pulse to the scalp and underlying brain of a person being evaluated or treated. It was evaluated for treatment of migraine based on the theory that a fluctuating magnetic field applied to the scalp would induce an electrical current which would disrupt the spread of abnormal brain currents (CSD) which is linked to the aura phase of migraineurs.

Recently a randomized, double-blind, sham-controlled trial evaluating the use of single-pulse transcranial magnetic stimulation was published. A total of 164 patients treated at least one migraine with aura attack as soon as possible after the aura onset. The primary endpoint or goal of this study was to determine if more patients were pain free at two hours who received treatment with TMS as compared to those who received the sham treatment; and this study did find a significant benefit of TMS versus the sham.

At two hours after treatment with the TMS, 32 of 82 (39%) of patients were pain free as compared to 18 of 82 (22%) of those treated with a sham treatment. However this trial was not able to show a reduction of pain from moderate/severe pain to mild/no headache pain at two hours. It is also not know whether multiple pulses would be more effective than stimulation with the two pulses such as done with single-pulse TMS. Finally, many more patients will be needed to evaluate safety concerns as it is theoretically possible that TMS could trigger seizures. In conclusion, TMS may be a promising and exciting new, non invasive, acute treatment option for patients with migraine with aura; however more research is still needed.

Barbara Lee Peterlin, D.O.
Drexel University of Medicine
Philadelphia, PA

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