The Effect of Single-Dose Propofol Injection on Pain and Quality of Life in Chronic Daily Headache: A Randomized, Double-Blind, Controlled Trial

Propofol for Treatment of Acute Migraine in the Emergency Department: A Systematic Review

OBJECTIVES

Propofol has not been extensively studied as an acute migraine therapy; however, based on the limited evidence from outpatient and inpatient settings, propofol has been proposed as an option for patients who present to the emergency department (ED). The purpose of this review was to evaluate the existing literature regarding the safety and efficacy of propofol for acute migraine treatment in the ED.

METHODS

A systematic review of clinical studies of propofol treatment for acute migraine in the ED was performed using Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Trials were identified through PubMed, Google Scholar, clinical trial registries, research registries, and key journals through May 2019. A modified Jadad scoring system was used to assess the methodologic quality of the included randomized controlled trials, and the Newcastle-Ottawa Scale was used for the retrospective cohort study.

RESULTS

Nine studies, including five case reports or series, one retrospective cohort study, and three randomized controlled trials, consisting of 290 patients, were reviewed. All studies in adults reported propofol to be an effective therapy for migraine, but the strength of these results was limited by dosing variations, small sample sizes, and limited generalizability. Pediatric studies produced mixed results.

CONCLUSIONS

Propofol may be an effective rescue therapy for patients presenting to the ED for acute migraine, but its place in therapy based on the limited available evidence is unknown. The safety of propofol for migraine management in the ED has not been adequately examined.

Mechanisms of Perceived Treatment Assignment and Subsequent Expectancy Effects in a Double Blind Placebo Controlled RCT of Major Depression

Objective: It has been suggested that patients' perception of treatment assignment might serve to bias results of double blind randomized controlled trials (RCT). Most previous evidence on the effects of patients' perceptions and the mechanisms influencing these perceptions relies on cross-sectional associations. This re-analysis of a double blind, placebo controlled RCT of pharmacological treatment of major depression set out to gather longitudinal evidence on the mechanism and effects of patients' perceived treatment assignment in the pharmacological treatment of major depression. Methods: One-hundred eighty-nine outpatients with DSM-IV diagnosed major depression were randomized to SAMe 1,600-3,200 mg/d, escitalopram 10-20 mg/days, or placebo for 12 weeks. Data on depressive symptoms (17-item Hamilton Depression Scale; HDRS-17), adverse events and patients' perceived treatment assignment was collected at baseline, week 6, and week 12. The re-analysis focused on N = 166 (out of the originally included 189 participants) with available data on perceived treatment assignment. Results: As in the parent trial, depressive symptoms (HDRS-17) significantly decreased over the course of 12 weeks and there was no difference between placebo, SAMe or escitalopram. A significant number of patients changed their perceptions about treatment assignment throughout the trial, especially between baseline and week 6. Improvement in depressive symptoms, but not adverse events significantly predicted perceived treatment assignment at week 6. In turn, perceived treatment assignment at week 6, but not actual treatment, predicted further improvement in depressive symptoms at week 12. Conclusions: The current results provide longitudinal evidence that patients' perception of treatment assignment systematically change despite a double blind procedure and in turn might trigger expectancy effects with the potential to bias the validity of an RCT. Parent study grant number: R01 AT001638 Parent study ClinicalTrials. gov Identifier: NCT00101452.

Parenting in the context of chronic pain: a controlled study of parents with chronic pain

OBJECTIVES

This study aims to describe what adults with chronic pain experience in their role as parents, utilizing quantitative and qualitative methods. The first aim was to compare parents with chronic pain to parents without chronic pain on perceptions of their adolescent's pain, parental response to pain, and catastrophizing beliefs about pain. The study also examined predictors of parental protective behaviors, and examined whether these associations differed by study group.

MATERIALS AND METHODS

Parents with chronic pain (n=58) and parents without chronic pain (n=72) participated, and completed questionnaire measures of pain characteristics and pain interference, as well as measures of parental catastrophizing and protective pain responses. Parents with chronic pain also completed a structured interview about their experience of being a parent. Interview responses were videotaped and subsequently coded for content.

RESULTS

Compared with controls, parents with chronic pain endorsed more pain in their adolescents, and were more likely to catastrophize about their adolescent's pain and respond with protective behaviors. Parent's own pain interference and the perception of higher pain in their adolescent was associated with increased protective parenting in the chronic pain group. Qualitative coding revealed a number of areas of common impact of chronic pain on parenting.

DISCUSSION

Chronic pain impacts everyday parenting activities and emotions, and impacts pain-specific parent responses that are known to be related to increased pain and pain catastrophizing in children and adolescents. Parents with chronic pain might benefit from interventions that address potential parenting difficulties, and might improve outcomes for their children.

Propofol and alfentanil in treatment of a patient with episodic cluster headache

Introduction:

Cluster headache is a severe hemifacial pain with concomitant symptoms such as lacrimation, conjunctival congestion, and nasal discharge. Peripheral (to be a spectrum of trigeminal autonomic cephalgia) and central (hypothalamus) disorders have been suggested to be involved. Several modalities have been recommended to prevent or alleviate this devastating headache.

Case Presentation:

In this case report, we presented a young man with an acute cluster headache who responded dramatically to the treatment with propofol and alfentanil.

Conclusions:

Propofol and alfentanil combination can be considered as a treatment approach in the attack phase of cluster headache.

Intravenous Sedation for Implant Surgery: Midazolam, Butorphanol, and Dexmedetomidine Versus Midazolam, Butorphanol, and Propofol

We compared the amnesic action, recovery process, and satisfaction of patients and surgeons after the use of 2 different sedation regimens for 40 patients undergoing scheduled implant surgery. Butorphanol, midazolam, dexmedetomidine (BMD) was administered to 20 patients who were maintained with continuous infusion of dexmedetomidine after the induction with butorphanol and midazolam, and butorphanol, midazolam, propofol (BMP) was administered to 20 patients who were maintained with continuous infusion of propofol after the induction with butorphanol and midazolam. To assess the amnesic action, the memory of local anesthesia, auditory memory, and visual memory were evaluated. The Trieger Dot Test (TDT) was applied during the recovery process. A questionnaire regarding the patient's feelings of the management of sedation was taken from each patient and was also filled out by the surgeon. The comparison between groups was analyzed by the Mann-Whitney U test. No significant differences in the amnesic action and the TDT were noted. Both methods also satisfied the patients and surgeons, as determined by the questionnaire results. In conclusion, both sedation regimens are appropriate for implant surgery.

Accurately Measuring Outcomes After Surgery for Adult Chiari I Malformation

BACKGROUND:

There has been a transition to using patient-reported outcome instruments (PROi) to assess surgical effectiveness. However, none of these instruments have been validated for outcomes of adult Chiari I malformation (CMI).

OBJECTIVE:

The aim of this study was to determine the relative validity and responsiveness of various PROi in measuring outcomes after surgery for CMI.

METHODS:

Fifty patients undergoing suboccipital craniotomy for adult CMI were prospectively followed for 1 year. Baseline and 1-year patient-reported outcomes (visual analog scale for head pain and visual analog scale for neck pain, Neck Disability Index [NDI], Headache Disability Index, SF-12, Zung Self-Rating Depression Scale, and EuroQol-5D [EQ-5D]) were assessed. A level of improvement in general health after surgery was defined as meaningful improvement. Receiver-operating characteristic curves were generated to assess the validity of PROi to discriminate between meaningful improvement and not. The difference between standardized response means (SRMs) in patients reporting meaningful improvement vs not as calculated to determine the relative responsiveness of each outcome instrument.

RESULTS:

For pain and disability, the NDI was the most accurate discriminator of meaningful effectiveness (area under the curve: 0.90) and also most responsive to postoperative improvement (standardized response means difference: 1.87). For general health and quality of life, the SF-12 PCS, EQ-5D, and Zung Self-Rating Depression Scale were all accurate discriminators; however, SF-12 Physical Component Scale (SF-12 PCS) and EQ-5D were most accurate. SF-12 PCS was also most responsive.

CONCLUSION:

For pain and disability, NDI is the most valid and responsive measure of improvement after surgery for CMI. For health-related quality of life, SF-12 PCS and EQ-5D are the most valid and responsive measures. NDI with SF-12 or EQ-5D is the most valid in patients with CMI and should be considered in cost-effectiveness studies.

The hidden effects of blinded, placebo-controlled randomized trials: an experimental investigation

The knowledge of having only a 50% chance of receiving an active drug can result in reduced efficacy in blinded randomized clinical trials (RCTs) compared to clinical practice (reduced external validity). Moreover, minor onset sensations associated with the drug (but not with an inert placebo) can further challenge the attribution of group differences to drug-specific efficacy (internal validity). We used a randomized experimental study with inert placebos (inert substance) vs active placebos (inducing minor sensations), and different instructions about group allocation (probability of receiving drug: 0%, 50%, 100%). One hundred forty-four healthy volunteers were informed that a new application method for a well-known painkiller would be tested. Pain thresholds were assessed before and after receiving nasal spray. Half of the nasal sprays were inert placebos (sesame oil), while the other half were active placebos inducing prickling nasal sensations (sesame oil with 0.014% capsaicin). The major outcome was pain threshold after placebo application. A substantial expectation effect was found for the inert placebo condition, with participants who believed they had received an active drug reporting the highest pain thresholds. Active placebos show substantial differences to passive placebos in the 50% chance group. Therefore, patient expectations are significantly different in placebo-controlled clinical trials (50% chance) vs clinical practice (100% chance). Moreover, minor drug onset sensations can challenge internal validity. Effect sizes for these mechanisms are medium, and can substantially compete with specific drug effects. For clinical trials, new study designs are needed that better control for these effects.