Episode 144: A heads-up look at the prevention of headaches - Part II
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In episode 144, Mike and James finish up their discussion about headache prevention with a poignant yet stirring discussion of the use of antihypertensive and antiepileptic agents for migraine prevention.
Comments
Placebo
Particularly in pain and insomnia placebo often has a success-rate of upwards of 20% and in other fields a NNT of 5 would be quite spectacular. But we are not supposed to lie to patients and therefore the use of placebo is frowned upon.
Is it ethically better to prescribe a (possibly expensive) medication with possible side effects in the full knowledge that it will probably work no better than placebo, rather than a cheap and harmless placebo tablet? And yes, I know that placebos have side effects too.
Please discuss
Love the show
Ralf
Hi Ralf - great question -
Hi Ralf - great question - first off it's important to realise the difference between the placebo effect and what happens in the placebo group. The big chunk of the 20% success is not the placebo effect but "tincture of time". Personally I feel their are too many ethical dilemmas to use placebos outside of clinical trials but I think the best way around the issue is to start with very low doses - 1/4 to an 1/8 of the normal dose - that way you can avoid many of the side effects and still get the effect of doing something (placebo?) and also the effect of the very low dose. Check out our paper in CMAJ on the low dose issue. CMAJ 2011;183:65–9
migraine prophylaxis
what are your thoughts on vitamin B2 (riboflavin) usage in migraine prophylaxis? A neurology colleague has advised it for my patient and suggests that 50mg/d titrating up to 400mg/d if needed has got some good evidence behind it. Listened to your podcasts but yuo didnt mention it. is it something you have heard of?
Dr Jen Heazlewood
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