Daith Piercings, The Vagus Nerve, and Migraines

September 9, 2019 / Thomas Cohn, MD

Daith piercings have been showing success in helping to control migraine headaches. Now there is new research that seems to shine more light on what has been thought to be the mechanism that contributes to the success of this treatment. Research into dementia has recently been done with stimulating the ear with a slight bit of external and intermittent vibration. The research suggests that this may help prevent dementia. The mechanism of action is thought to be by stimulating the ear, a branch of the vagus nerve is also being affected and this is what is producing the results. Similar to what we assumed was happening with the daith piercing, vagus nerve stimulation is the key factor at play.

The latest information on stimulating the ear and the vagus nerve comes from a study out of England and the University of Leeds (Bretherton et al, 2019, in Aging). Stimulating the outer ear for 15 minutes a day for two weeks with gentle electrical vibratory signals improved the relaxation signals and parasympathetic activity. The researchers determined that they were electrically stimulating a branch of the vagus nerve that is in the region of the tragus. In older people (55 years and older) they may have a high sympathetic outflow and this leads to stress, tension, depression and low energy. The transcutaneous electrical stimulation of the ear rebalanced the system and seemed to slow the effects of aging. The major caution was this was a small study so one does not know if these findings would be present in a large controlled study.

The initial research at the University of Leeds in England was done in 2015 and was done in healthy young people. Stimulating the ear with transcutaneous electrical stimulation at the vagus nerve improved autonomic function. Normalizing autonomic function means decreasing sympathetic tone, stress, tension and most likely vascular tone. This would also mean blood vessels would not constrict and could impact the occurrence of migraine headaches.

What It Means For Migraines

Vagus nerve stimulation has a history that is long standing. Vagus nerve stimulation devices were implanted after 2005 for treatment of major depression. They also have been used for gastro-intestinal disorders, epilepsy, and some inflammatory disorders. Now there is an FDA-approved device (GammaCore) to stimulate the vagus nerve through the skin to relieve migraine headaches.

Daith piercings we now know are not placebo treatments for migraine headaches. It is pretty clear they work through stimulating the auricular branch of the vagus nerve in the region of the tragus in the ear. Stimulating the vagus nerve will increase parasympathetic activity and decrease excessive sympathetic tone. This would likely decrease the vascular events that surround migraine headaches. Furthermore it may reduce overall personal stress and anxiety that may be migraine triggers. The piercing would cause physical stimulation of the vagus system and thus rebalance the autonomic nervous system in the body. If piercing is not an option, then using a transcutaneous nerve stimulator (TENs) unit with a very light current to the tragus unit would likely do the same. The good news is that science is validating the practice of this piercing.

As a side note, research is underway specifically on the daith piercing. Studies are being done in England and elsewhere in Europe with regards to the effectiveness of this technique. Whether the daith piercing will work for any one individual is unknown. Since migraines may have a number of triggering causes, the effectiveness of the daith piercing is likely dependent on whether a component of the migraine is related to autonomic balance in the body and if it can be corrected with vagus nerve stimulation. Hopefully we continue to learn more about vagus nerve stimulation and how to best treat these types of migraines in the near future.

New Technologies For Pain Management

August 19, 2019 / Thomas Cohn, MD

Medicine is evolving as electronic technology invades all aspects of medical care, and pain management is no exception. The areas that have changed the most are imaging technology and implantable devices. What is interesting to patients is how imaging can improve care and implantable devices may help when nothing else is working. The improved imaging makes diagnostic and treatment decisions easier and also makes interventions more precise when tied to management by an astute clinician. No matter how good the technology is, without the skill of a good clinician to understand the medical problem, no solution would be helpful.

The new implantable technology available is peripheral nerve stimulation. This is designed for treatment of pain that is related to damage to a peripheral nerve, such as in the arm or leg. Pain can often be traced to an isolated nerve and preventing that nerve from propagating the pain signals helps to control the problem. These pain issues arise sometimes after amputations with phantom pains, and can be seen after trauma when nerves are damaged. These problems can also occur with surgeries like joint replacements, orthopedic interventions, spinal operations and some fractures. When the pain is not resolving and an isolated set of nerves can be found and successfully blocked with local anesthetic, then nerve stimulation may be appropriate. This is a treatment to consider when simpler interventions like medications, physical therapy, and injections have not been successful.

Nerve Stimulation For Pain Management

The idea of peripheral stimulation has been around for a long time. In the distant past, traditional spinal cord stimulators were used for peripheral nerve stimulation. Unfortunately, at some point this began being abused and since those systems were extremely expensive, this process stopped. In the last two years, new systems have been designed specifically for peripheral nerve stimulation that are very technologically advanced and effective.

One example is electrode stimulation. The electrode is a very thin wire coated in silicone that can be delivered to the right place along the specific nerve with a needle guided by ultrasound imaging. The wire contains a special signal receiver that can be used to help stimulate the nerve and drown out pain signals. Most importantly, the signal generator is now a very small rechargeable unit that is placed on the skin over the end of the electrode. In the near future the electrode may connect even further from the generator such that it may be able to be carried in a pocket or other safe place.

The new technology is FDA approved for peripheral nerve pain from any type of nerve injury. The easiest insurance approval is Medicare, but other providers are starting to approve of such treatments when proven simpler treatments have failed. There currently are at least two manufacturers of equipment, the difference appears to be mainly in the generator’s ability to deliver a variety of signals that may effectively block pain signals and not be uncomfortable to the patient. From experience developed in spinal cord stimulation, the electrical signals can be varied such that the nerve pain is blocked but the patient does not feel any other odd sensations. The net effect is that one can perform activities that were once painful without the ongoing sense of pain.

For pain patients, this new technology is nice since the only thing implanted into the body is a thin wire to the appropriate location. Testing prior to implant is first by a local nerve block with a long lasting anesthetic. If that is successful, than a trial implant can be done for a week or longer to determine if a final implant would be indicated. The permanent implant is a brief outpatient procedure and can be easily removed in the future if necessary.

Pain patients who may benefit from peripheral nerve stimulators include those where pain symptoms have a definite peripheral nerve origin and the pain can be extinguished by blocking just one or possibly two nerves that are nearby each other in the body. The first problems that have been treated have been pain related to shoulder injuries that do not resolve with surgery. Other common orthopedic problems include knee and foot pain after trauma or other surgery with nerve damage or nerve pain afterwards. Amputation phantom limb pain and complex regional pain syndrome are other pain problems that may benefit from this technology. An interventional pain specialist who does implants should be able to help determine if the pain problem may be helped with such treatment. Not all pain problems can be helped and if the pain is coming from multiple pain generators or is centrally generated in the brain, this treatment is less likely to be helpful.

The Benefits and Drawbacks Of Extended Release Opioids

July 29, 2019 / Thomas Cohn, MD

We are always looking for new ways to make painkillers safer for those individuals who suffer from acute or chronic pain conditions, and one such improvement was the shift to extended release opioids. These types of pills were promoted as safer than traditional opioids, and while they are in some aspects, they are far from a perfect solution. In today’s blog, we take a closer look at the benefits and drawbacks of extended release painkillers.

Extended Release Painkiller Benefits and Drawbacks

Here’s a look at some of the benefits of extended release painkillers, as well as some reasons why these benefits may not be a perfect solution to the problem.

Abuse Deterrent – Some painkillers were redesigned, making them harder to crush and snort. While this has been successful in preventing abuse of some opioids, it has led some abusers to try even more dangerous methods to get their quick fix, like in the form of injections with shared needles. Other types of abuse deterrent drugs actually were designed such that if they were crushed, the active ingredient would fail and the user would not be able to experience the drug’s effects, which helped prevent abuse.

Overdose Deterrent – Extended release formulas of some opioids mean that the individual taking the medication gets a mild amount of the drug over an extended period of time, as opposed to a quicker feeling of pain relief that patients might feel with normal formulas of the drug. This also means patients may need less of the drug because it provides longer and consistent relief instead of a stronger relief that fades over time. That being said, some people may be expecting quicker pain relief, and when they don’t achieve that soon after taking the pill, they could end up taking additional pills to quell their pain. This can lead to an increased likelihood of abuse, addiction or accidental overdose.

Easy To Find – Many companies were forced to invest in developing abuse-deterrent versions of their drugs, so there are a number of different ER opioid options. However, since companies needed to invest more time and money into developing these drugs, they are often more costly than the normal pills. Many patients don’t want to spend more on painkillers than they need to, meaning many opt against the extended release options.

Effective – The good news is that for many patients, ER opioids are effective at helping them manage pain. One thing many pain sufferers want is consistency, and a consistent, long-release drug can do all that. This can help them plan their day, including when they need to take the pills in order to participate in physical therapy or other active treatment options. The only issue is, like any drug taken over a long period of time, the body gets used to the drug and a higher dose is needed to achieve the same level of relief. ER opioids are great in the short-term when working towards a longer recovery goal, but like any opioid, should not be viewed as a long term solution if at all possible.

Relearning How To Sleep With Chronic Pain

July 22, 2019 / Thomas Cohn, MD

Chronic pain can make daily tasks seem impossible, and one of the most common areas of your life affected by chronic pain is your ability to fall asleep and stay asleep. For many people, they need to relearn how to achieve quality sleep because it no longer comes naturally thanks to their pain condition. In today’s blog, we share some tips for relearning how to get restful sleep, because quality sleep plays an important role in controlling chronic pain.

Getting A Good Night’s Sleep With Chronic Pain

Here are some tips for falling asleep and staying asleep if you deal with a chronic pain condition.

1. Regular Bed Time – Get in the habit of going to bed around the same time every night. You body has what’s known as a circadian rhythm that helps regulate awake and tired periods for your body, and if you get up and go to bed around the same time, this will help you body find a good circadian rhythm. Even if you struggle to fall asleep right away, going to bed and laying down around the same time at night will help your internal body clock.

2. Lose The Distractions – The bedroom needs to be a place for sleeping, not for reading on your iPad or clicking around on Netflix. Research has shown that the bright lights of screens in dark rooms can stimulate our brain at a time when we want to be winding down. Read or watch TV out in the living room so that the bedroom becomes a place where you focus on achieving quality sleep.

3. Avoid Caffeine and Alcohol – In the hours before bed, avoid certain liquids that can inhibit restful sleep, like caffeine and alcohol. Even though alcohol may help you fall asleep, it disrupts your ability to achieve REM sleep, the deep and quality type of sleep you need to receive. Avoid these liquids as the sun begins to set.

4. Water Intake – If you’re looking for something to drink, go with water, but make sure you’re cognizant about your water intake. If you’re even slightly dehydrated when you go to bed, it can cause your mouth and nasal passages to become dry and lead to disruptive snoring. However, drinking too much water can lead to the need to get up and go to the bathroom in the middle of the night. Play around with your water intake in the hours leading up to bed so you are hydrated when you crawl into bed.

5. Temperature and Noise – Finally, the key to quality sleep is to stay asleep once you’re out. You don’t have a lot of control over this, but you can help by ensuring your bedroom has the right temperature and noise level. Keep the room cool and use blankets to get comfortable, and find out if noise helps or hinders your ability to fall asleep. Some people like white noise machines, others like the drum of a fan, while others need complete silence. See what helps you fall asleep and stay asleep, and then recreate those conditions each night.

For more tips on falling asleep if you have chronic pain, or for help with your specific pain condition, reach out to Dr. Cohn’s office today.

Tips For Managing Chronic Pain During The Summer

July 2, 2019 / Thomas Cohn, MD

The summer should be one of the most enjoyable times of the year in Minnesota, but for many people who deal with chronic pain, the summer heat can make their condition worse. So how can you not only survive, but thrive, during the summer months if you have chronic pain? Consider this blog your playbook to managing your pain condition this summer.

Handling Chronic Pain in the Heat

Here are a number of ways to fight back against your chronic pain condition during the summer:

Exercise During Non-Peak Hours – As we talk about on this blog all the time, exercise is very important to help strengthen key structures and treat chronic pain conditions. However, if you’re exercising when it’s hottest out, it can trigger a flareup or lead to a less than successful exercise session. Wake up early or exercise when the sun goes down to avoid the heat.

Dress For What’s Ahead – Becoming overheated can trigger a pain flareup or make your CRPS worse, so look ahead at the weather and plan accordingly. Wear appropriate clothes for the day and try to be inside when it’s supposed to be the hottest to avoid problems with your pain condition.

Swim – Swimming is one of our favorite exercises during the summer, because not only does it get the heart pumping and strengthen supportive muscle groups, but it also helps to keep you cool. On days when you don’t want to do a traditional workout outdoors, head to the community pool or a nearby lake to do some swimming. If you want help developing a water-based exercise routine to treat your pain condition, reach out to our office today.

Stay Hydrated – Pain conditions can also trigger if you’re dehydrated, as can other problems like an increased risk of muscle strains and sprains. Make sure you bring water if you’re going to be outside for long periods or if you’re going to be sweating.

Stay Inside – Finally, if you don’t have to go outside and take on the heat, stay inside where it’s cool. Do your workout inside where it’s cool, or go for a run indoors on your treadmill. It’s important to stay active even when indoors to help keep healthy blood pumping throughout your body, but don’t go out in the heat if you know it’s going to cause problems for your pain condition.

If you follow these tips, we’re confident that you’ll be able to take control of your pain condition even in these hot months. And if you need additional assistance with any aspect of your pain condition, reach out to Dr. Cohn’s office today.