health

Irritable Bowel Syndrome

Cramping abdominal pains, bloating, diarrhoea or conversely bouts of constipation: these are all common symptoms of Irritable Bowel Syndrome (IBS).  It’s a pretty common problem thought to affect 10-15% of the population with only 10-20% of sufferers ever going to see their GP.  It’s far more likely to occur in women than men (2:1 ratio female to male sufferers) and commonly affects people in their 20s and 30s.

I’ve been driven to write about it because these are symptoms I see every day in General Practice and have personally suffered with and I’ve found that once it’s been diagnosed it can almost be… dismissed.

“It’s just IBS.  No need to worry”.

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Unfortunately there are studies which show that, although IBS doesn’t limit the length of peoples lives, the quality of the lives sufferers lead can be impaired causing psychological issues and financial losses through missed time at work.

Case: Laura

Last month my friend Laura started to develop severe cramps in her stomach.  She felt sick, bloated and she started having bouts of diarrhoea.  This was unusual for her: she’s very healthy and is rarely off work.  She’s also self-employed so any time she does need to take off is unpaid.  So she took some antacids and just powered through it.  Her pain continued.  It was so bad one night that she called 111 and was advised to go to A&E.  It was December and we were in the grips of yet another winter crisis for the NHS: the hospitals were full to the brim and the staff overworked.  They assessed her and told her it was probably gastritis.  Take some Omeprazole and see your GP.

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The pain continued.  She could barely eat over Christmas.  The pain was intermittent: she’d have periods of time where she thought she was better and go into work only for the pain to come on quickly and be so severe she’d have to return home.  She went to her GP who was very thorough.  She’d been diagnosed with IBS in her early 20s but never had any advice or testing for other things.  He wasn’t particularly happy about this “we should really make sure it isn’t any thing else”.  He arranged for a blood test (including a test for Coeliac’s Disease which is a gluten-allergy) and stool tests to check for a bug called H Pylori which can cause gastritis and another called a faecal calprotectin (to check for inflammation).

Off she went again, waiting for the results of the tests.  On my advice she’d started trying to track her symptoms to see if they were associated with any specific foods.  The blood tests and stool tests were all normal and she’d realised that her symptoms were worse every time she ate anything containing dairy.

What causes IBS?

Ok this is another syndrome where we don’t fully understand the processes involved but it is likely to be linked to a number of factors.

  • Genetics: no specific gene has been identified but twin studies suggest this has a role.

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  • Diet: this includes intolerances and sensitivity to certain foods and up to 90% of people suffering with IBS report certain food triggers
  • Infection: some people seem to develop IBS after gastroenteritis due to changes in the normal constituents of the gut due to the immune-response and normal bacteria which make up the gut flora.
  • Psychological factors: psychological stress due to anxiety or depression can alter the functioning of the bowel.  This is due to the presence of the “brain” around the gut (a complex neurological system which exists around the gastrointestinal system).

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  • Medications: such as antibiotics

How is IBS diagnosed?

This is tricky.  There is no definitive test to confirm the presence of IBS: it’s made by looking at the pattern of symptoms and, if necessary, ruling out other causes.  Laura’s GP was correct: her symptoms were quite severe so it was worth making sure that she was tested appropriately.  But to be honest, this may not always be appropriate and it does depend on the pattern of symptoms and how certain the doctor seeing the patient is about the diagnosis.

I personally think a symptom diary can be invaluable.  Cutting out whole food groups at random always seems to be en vogue but it can lead to deficiencies which can endanger health and wellbeing.  Keeping a diary can help to identify any patterns of symptoms and make it easier to see if certain food groups trigger them.

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If testing is recommended I would always advise being checked for a gluten allergy (Coeliacs Disease) because it can cause similar symptoms.  Before this blood test is carried out you should make sure you’ve been eating wheat for at least 2 weeks otherwise it may be negative even if the disease exists.

Diet and lifestyle

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The most popular treatment option for sufferers of IBS (according to the BMJ) is the low FODMAP diet.  The term FODMAP relates to a new dietary class comprising of fermentable oligosaccharides, disaccharides, monosaccharides and polyols: a list of foods which ferment and thus are poorly absorbed.  This includes common foods such as:

  • Fruits (apples, cherries, peaches and nectarines)
  • Artificial sweeteners (sorbitol, xylitol and mannitol)
  • Vegetables and legumes (including broccoli, Brussels sprouts, cabbage and peas)
  • Most lactose-containing products

This diet is restrictive which can make it difficult to stick to.  Evidence from the trials shows that even short term adherence to the diet can lead to better gut health.  The longest duration of the diet in these trials seemed to be 6 weeks but even sticking to it for as little as 3 can be beneficial.

Ideally this diet should be adopted under the guidance of a dietician but there is a good factsheet from the IBS Network.

The NICE guidance also advises that probiotics purchased over the counter may have some benefit but the evidence from trials is limited and the probiotic should be tried for between 4-6 weeks.

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Exercise and regular physical activity are also advised in the management of IBS.  Theoretically, regular activity reduces bloating and gas retention and it is known that regular exercise reduces stress levels.  There have been some small trials which show that there was a significant reduction in IBS symptoms in patients who undertook a regular exercise programme compared to those who did no exercise.

Medications

There are no specific medications for IBS at present but the choice of medications should be based on the nature and severity of the symptoms.  The different medications can either be used in isolation or combination:

  • Antispasmodics such as Meberverine Hydrochloride or Peppermint Oil for abdominal cramps as required
  • Laxatives (but not Lactulose) for constipation symptoms.  The specific laxative Linaclotide can be prescribed for moderate-severe constipation in IBS if:
    • constipation has persisted for more than 1 year
    • all the other types of laxatives have been tried and failed
  • Anti-motility agents such as Loperamide for diarrhoea-type symptoms
  • Antidepressant medication can be tried if laxatives, antispasmodics or anti-motility agents have not worked.
    • Tricyclic Antidepressants (TCAs) such as Amitriptyline.  As with its use in migraine this would not be used to treat a suspected depression but for its neuropathic painkilling effects.
    • Selective Serotonin Re-uptake inhibitors (SSRIs) such as Citalopram or Fluoxetine if treatment with a TCA has been ineffective or poorly tolerated.

Cognitive Behavioural Therapy (CBT)

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Use of psychological therapies such as CBT has been advised for many years now, but uptake of such treatment is low, possibly because of the stigma associated with suffering with a “mental health disorder”.  The studies show that there can be some benefit from CBT in the initial stages following treatment but the benefits are vary according to the practitioner providing the treatment, the patients adherence to the treatment and the number of sessions which are provided.  This is still advised in the NICE guidance for IBS which does not respond to lifestyle changes or medications.

What next?

If none of the above is beneficial a referral to a gastroenterologist should be made to confirm whether or not IBS is indeed the diagnosis and for guidance on further management.

For more information please see:

The gut and liver disease charity CORE

The IBS Network

The Association of UK Dieticians factsheet on IBS and diet

Headache

Medication Overuse Headache (MOH) – detoxing

In the article about acute treatment, I briefly discussed the problem of medication overuse headache (MOH).  This can be a problem in patients who suffer with migraine, tension-type headache, cluster headache and other headache disorders but is much more common in migraineurs.

It happens when people take pain-killers for too many days over a 3 month period: this ends up causing the headache instead of treating it.  The resulting headache can be more severe and unrelenting causing the sufferer to take more medication and… the problem continues.

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It’s a frustrating paradox for the sufferer and can be difficult to get your head around (pardon the pun).

It can happen with any headache medication but for guidance I have made a list of the common ones and how often you have to take them to cause this problem:

  • NSAID medications such as ibuprofen, naproxen or aspirin and other simple pain-killers such as paracetamol are taken on more than 14 days a month
  • Triptans are taken on more than 8 days a month
  • Codeine and other opioids are taken on more than 6 days a month
  • Ergots (an old fashioned migraine treatment) more than 10 days a month

The key point to remember is it’s the number of days not the number of doses that counts.

How do I work out if I have MOH?

I do keep bleating on about migraine diaries but I find them invaluable for teasing out a pattern or helping to work out what’s causing migraine or headache.  If a diary is kept it quickly becomes obvious if someone is using too many pain-killers: you only need to take a triptan 2 days a week or paracetamol for more than 4 days on a weekly basis to cause MOH.  It’s difficult to keep track of this without noting it down.

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What do I do?

This is the difficult part.  You have to stop taking pain-killers.  It’s tough… really tough.  I liken it to a detox: initially when the medication in question is stopped the headache gets worse.  It’s really important to be aware of this because the temptation is to reach into your purse and grab the ibuprofen to make the pain go away.  But that would be a mistake because you’d just be delaying the inevitable and your frequent headaches would continue.

The amount of time it takes to detox is dependent on which medication is causing the issue.  If the problem is a triptan, NSAID the withdrawal headache will last for 7-10 days.  If it is a simple pain-killer it’s 2-3 weeks and if codeine or an opiod is the problem it’s 2-4 weeks.

How long do I need to “detox” for.

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We advise 12 weeks to allow the medication to wash out of the system.  If there is more than one medication that is being overused it is sometimes better to stop one medication at a time.

Can anything be done to help?

There are a few options:

  1. Naproxen: this is only a possibility if you have not taken this medication much before.  This can ease the withdrawal headache.  We often start a 6 week course starting
    • 3 times a day for two weeks
    • 2 times a day for two weeks
    • 1 time a day for two weeks
  1. Greater Occipital Nerve Block: injection of steroid with local anaesthetic at the back over the head around the nerves that supply the scalp.  It works by blocking the abnormal pain signals that fire during MOH.  Typically it gives relief for up to 6 weeks: just long enough to detox from the medication.
  2. Preventative medication: see full article but often we use Amitriptyline to dampen the withdrawal headaches.

For more information please see:

The National Migraine Centre factsheet.

Headache

Migraine Triggers

In my post on acute treatment I discussed preventing migraine attacks by identifying triggers.  Triggers can be internal or external and are essentially any change or event which causes a migraine to occur.

How do triggers cause migraine?

Every individual who suffers with migraine will have a “threshold”.  I like to think of this as a line: anything which pushes you over the line will cause a migraine, and the factors which push you over the line are your triggers.  These triggers tend to be multiple and work together but some will be stronger or more potent than others.

triggers
Migraine Triggers National Migraine Centre

How can I spot my triggers?

There are a few useful facts about migraine that are instrumental in identifying triggers:

  1. Migraine takes 12-24 hours to develop, which is much longer than most people suspect
  2. Different people have different triggers what causes migraine in one individual may not in another
  3. Migraine thresholds vary. That line I discussed above can move up or down at different points in your life: this can make “new triggers” appear if your line is particularly low as you are more susceptible to its effects than before.

What sorts of things act as triggers?

As I have said, triggers vary greatly from person to person but there are a few themes that are common to most people who suffer with migraine and I will list some examples:

  • Diet: You just have to enter the word migraine into a search engine and lots of posts about specific food triggers like cheese, chocolate and citrus will come up.  Although specific triggers do exist, these have largely been disregarded by headache professionals.  Historically, when people have tracked their migraine they have identified that they would ingest cheese, chocolate etc two hours before attacks: these must be triggers right?  Unfortunately not.  They are now thought to be cravings brought on by a drop in blood sugar level before the migraine starts.  However, rapid changes in blood sugar level can act as a migraine trigger so I advise people to avoid fast-burning carbohydrates (i.e. very sugary foods) where possible and concentrate on a high-protein diet eating slow burning (i.e. brown rice, brown pasta etc) carbohydrates where possible.  People should also avoid skipping meals and consider adding in healthy snacks during the day and before bed-time to prevent their blood sugars from fluctuating to often.

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    • Sleep:  changes in sleep pattern are another common trigger.  Many people identify lack of sleep as a trigger but do not always think about their sleep routine: shifts in this normal pattern of even up to an hour each way can precipitate a migraine.  An example of this is a weekend where someone may have stayed up an hour later on the Friday night or treated themselves to a lie-in on the Saturday morning.  This can be one of the factors that results in a weekend migraine.  It can also be a particular problem for shift-workers as I certainly found when rotating through my hospital jobs.
    • Stress: this emotion does get implicated in a lot of medical and psychological problems but it certainly has a role in migraine.  Often it is noted that the migraine occurs when the stress has been alleviated (i.e. when people relax).  However, other emotions can trigger migraine too: anger, excitement, sorrow, joy… this can be particularly evident in children who often have attacks when they’re excited about events such as birthday parties or trips out.

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  • Hormones:  a study at the National Migraine Centre showed that 50% of women were more likely to suffer a migraine attack at the time of their period.  Menstrual migraines exclusively occur during a woman’s period but most women have attacks at other times of the month too which means this is one of their triggers but not the entire cause.  Some women who are sensitive to hormonal changes benefit from regulation of their cycle with the contraceptive pill or coil, unfortunately this can exacerbate symptoms in others.  Women who are hormonally sensitive may find their migraine attacks are much worse around the menopause and thus can benefit from HRT.
  • Neck and back pain: any type of muscular or joint pain in the neck and back can exacerbate migraine.  This can be as simple as poor posture or a muscular injury.  This can be improved with gentle exercises, physiotherapy or osteopathy.
  • Light sensitivity: although this can sometimes be a prodrome rather than a trigger, some people are light sensitive between migraine attacks and this can contribute towards causing further migraines.  Computers or VDUs can be a source of this and it is the blue-green wavelengths emitted which are troublesome.  There are programmes available which act as a screen filter and some people benefit from tinted lenses on their glasses.  Taking frequent breaks from looking at a screen is also important.

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Why should I bother?

Most people who have migraine do not want to take medication, and taking too much can lead to problems such as medication overuse headache.  If you can identify your triggers and try to eliminate them through life-style measures you can reduce the number of attacks you have (some studies show by 50%!).  The way to identify these triggers is to keep a diary.

For more information see:

The Migraine Trust – Triggers

The National Migraine Centre Factsheet

Headache

Treating Migraines (acute treatment)

So you’ve established you suffer with migraine.  So what do you do?  As I’ve said before, I didn’t used to do much to help myself.  I’d take the wrong pain-killers and suffer through my day and I know, from my job as a headache specialist, countless others do the same.

Treatment is divided into two types: acute (immediate) treatment and preventative treatment.

This is to get rid of the symptoms you experience during a migraine.  The easiest way to work out what to take is to know why your taking it:

1.  Domperidone (anti-sickness or pro kinetic medication)

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The first medicine I advise to take is Domperidone and it helps with nausea and vomiting.  This occurs because the stomach is directly affected by the migraine process: it stops emptying in a process called gastric paresis.  This means anything sitting in the stomach cannot move forward into the part of the gut where it will be absorbed.  This happens in all migraine regardless of whether or not people feel queasy.  Gastric paresis also means that any medicines taken won’t be absorbed properly.  The main function of Domperidone is get the stomach to empty (termed pro-kinesis) and this helps any pain-killer to work better.

2.  Soluble Aspirin

The next medication is a good old fashioned pain-killer: Aspirin.  This has largely fallen out of favour as a analgesic for most conditions but it works well for migraine and headache.  Because the gut has slowed down it is best to take this in the soluble form so it is better absorbed.  Better still, it should be dissolved in a sugary, fizzy drink.  The fizz helps improve the absorption of the aspirin.  The sugar helps to reverse a drop in blood sugar that occurs before the migraine starts (often making people crave sweet or salty food such as cheese or chocolate… more on this in the article about triggers).

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Other non-steroidal anti-inflammatories (NSAIDs) such as Ibuprofen or Naproxen can be used at high dose if this does not help. This is not a suitable medication if you suffer with gastritis or for some asthmatics so I would advise speaking to your GP if this applies to you.

3.  Triptans

If the migraine is severe or if the symptoms don’t improve 45 minutes after steps one and two have been take a Triptan should be tried.  This class of medicine are specific painkillers developed for the treatment of migraine and headache.  There are 7 of them on the market and treatment usually starts with the first one that was developed: Sumatriptan (Imigran) which is available over the counter.

Some people find they can have side-effects (usually drowsiness or nausea) with this medication or it is not effective.  It can be tried in higher doses via the GP or taken via a different route if it does not work fast enough (a nasal spray and self-injection are available).  If it is not suitable, one of the other 6 triptans can be tried.

Is there a limit to how often I can take pain-killers?

In a word: yes.  Unfortunately, if you suffer with migraine you can develop a problem called Medication Overuse Headache.  It’s a strange phenomenon which seems only to affect people who suffer with headache disorders, most commonly migraine.  It happens if you take too many painkillers in a month for 3 consecutive months and causes a more severe headache or worsening of migraine features.  As a guide it occurs if:

  • NSAID medications such as ibuprofen, naproxen or aspirin and other simple pain-killers such as paracetamol are taken on more that 14 days a month
  • Triptans are taken on more than 8 days a month
  • Codeine and other opioids are taken on more than 6 days a month.

If you think this may be a possibility, I would advise speaking to your GP about how to detox from painkillers and consider whether a preventative medication may be suitable.

Are there any medications I should avoid?

Yes. There are some strong pain-killers which are not suitable for the treatment of migraine.  The advice of most headache specialists is that patients who suffer with migraine should avoid codeine and other morphine-type medication (opioids).  They are not particularly helpful in getting rid of migraine symptoms and often worsen the gastric slowing I described earlier.  They also are prone to cause rebound-headaches.  They are often prescribed by doctors due to the fact that migraine can be very painful but they should be avoided at all cost where possible.

What can I do to stop getting migraines?

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Most people don’t like taking medications.  This is where migraine prevention comes in.  The most effective way to stop having migraine is to identify what your triggers are.  These are different in everyone but I have written an article to help identify them.  Again, keeping a diary is key to identifying what your triggers are.

If you find you are suffering with migraines more than 4 times a month, or if they are so severe they are stopping you from effectively carrying out your daily life, it is worth considering preventative treatment.

health

Sleep

Insomnia affects one third of the UK population.  That’s a staggering number of people who suffer with difficulties sleeping.  Insomnia is defined as a difficulty getting to or sustaining sleep or not having good quality sleep all of which cause problems with daily functioning (namely concentration), low mood or day-time sleepiness.  In a nutshell it’s poor quality sleep and it has a big impact on people’s lives. It is thought that 10-50% of patients seen by GPs suffer with insomnia.  When you run a search using “insomnia” as your criteria a multitude of papers with slightly alarming titles come up:

“insomnia increases risk of heart attacks and stroke”

“insomnia is linked to risk of gestational diabetes”

“insomnia increases risk of developing asthma”

The list goes on.  So aside from affecting peoples psychological health and ability to function it is also linked to some pretty serious health problems.  Therefore, it’s a big deal.

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I’d agree with the statistic above: at least one patient a day visits me to talk about difficulties sleeping and more tend to mention it as an also-ran when discussing their other health problems.  It’s a diagnostic feature of depression (early-morning wakening) as well as a key feature of anxiety (waking up in the night, difficulty getting to sleep) but given the fact that lack of sleep causes mood problems which one comes first?  Or is it just a vicious cycle?  If the long-term effects are so serious what can we do about it?  And why are GPs so reluctant to prescribe sleeping pills?

Causes

The causes of insomnia are seemingly never-ending.  As mentioned above, the most common cause is anxiety and depression affecting almost half of patients experiencing sleep difficulties.  One cause is the presence of another medical condition such as asthma (if it’s badly controlled people tend to cough at night), thyroid disorders, pain due to joint disorders and heart problems which leads nicely to the next cause: medications that we give to treat these conditions.  Anti-depressants can cause sleep problems as can medications used to treat asthma such as salbutamol (commonly known as the reliever inhaler) and steroids which are used for the treatment of asthma and other inflammatory conditions.  As well as drugs we give, drugs (legal or otherwise) that people choose to take recreationally can also cause insomnia.  I include caffeine, alcohol and nicotine in this list.  Then there are the sleep disorders…

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Sleep Disorders

The most common of these is obstructive sleep apnoea.  This is a condition where the air-ways become blocked for a period of time.  The person appears to stop breathing and the lack of oxygen causes them to rouse partially so the airways can open again.  Understandably this does not result in a  great nights sleep and people can feel very drowsy during the day, falling asleep more readily than is normal.  This condition can be assessed before you go and see a doctor: snoring is an almost universal feature of this condition but partners often report frightening “pauses” in breath.  If this is the case it’s worth doing the Epworth Sleepiness Scale.  If the score is over 10 a referral should be made to a sleep clinic for further assessment.  Before it gets to the stage of requiring machines to help keep the airways open overnight (CPAP) or devices to wear in the mouth, life-style changes like losing weight, stopping smoking, reducing alcohol intake and stopping sedative treatment can help.

Changes in the normal sleep pattern (Circadian rhythm disorders) such as jet-lag and shift work can cause insomnia.  This type of problem is characterised by difficulty going to bed at the same time as normal people do a sleeping longer with marked difficulty in waking.  And the final sleep disorders are parasomnias a group of disorders with include restless leg syndrome and sleep walking.  If no cause can be found then a diagnosis of “Primary Insomnia” is reached.

What can you do about your sleep

I often feel patients are disappointed the first time they come to see me about their difficulty sleeping.  Unfortunately there is no “magic bullet” many people desire.  Once I’ve assessed their sleep pattern and tried to ascertain a cause I usually talk about “Sleep Hygiene”.  This is the phrase we use to describe measures that can be adopted to promote good sleep and incorporates changes to the sleep environment and behaviour.

  1. The first thing to do is establish a routine.  Go to bed and wake up at the same time, this avoids the problem of oversleeping and the body often responds well to routine.  Developing a relaxing bed-time ritual (i.e. a cup of herbal tea followed by some reading time) can be beneficial.
  2. Avoid caffeine or alcohol 6 hours before bedtime and consider cutting it out altogether.
  3. Avoid screen use (TV, computer, mobile phone) for up to an hour before bed.  The light-rays from these screens is very stimulating and can delay sleep initiation.

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  1. Don’t take naps during the day
  2. Avoid exercise within 4 hours of bedtime but do exercise regularly during the day.
  3. Only use the bedroom for sleep (or sexual activity).  So if you can’t fall asleep and you’ve been trying for more that 30 minutes get up.  Also try to avoid doing work in the bedroom.  You are less likely to associated the room as a place of rest and this can result in trouble sleeping.

It has been reported that 30% of people improved with the above measures alone.  If none of these measures are beneficial and the problem has persisted for 4 weeks or more it is worth completing a sleep diary and seeing your GP as they may want to check for some of the conditions listed above.

What about sleeping tablets

Once upon a time doctors gave out sleeping tablets like they were going out of fashion.  Now you may have noticed we’re a lot more cautious.  I am sure I’m not alone in feeling wretched when I hear someone sit down and say “I’d like to have some sleeping pills” largely because I know they are likely to leave disappointed.  It’s not because we’re being difficult or trying to deprive people of that elusive good nights sleep, but the risks of taking hypnotics or sleeping pills far out-weigh the benefits.  Simply put: they’re dangerous.  And most of them are highly addictive.  If people have tried all the measures above, and they understand that medications are to be used as the exception, not the rule, I will advise that they can try over the counter medications.  These include the natural supplements and antihistamines you can get from the chemist.  If they fail I may prescribe a very limited prescription for a dreaded “Z” drug.  They can be useful when used for less that 4 weeks but they do not guarantee good sleep quality so the effects of insomnia may remain despite taking these pills.  The other issue is stopping them, they are addictive as I’ve said before, but they also cause a rebound-insomnia when they are stopped.  Unusual sleep behaviours have been reported on hypnotics such as “sleep driving” without remembering the event.

What will work?

If insomnia is caused by an underlying condition such as asthma or a heart problem, treatment of this should resolve the sleep difficulties.  Reduction in caffeine or alcohol at night will help with issues caused by stimulation from these drugs.  There are sleep therapies which can help.  The first is Cognitive Behavioural Therapy (CBT) which is a psychological talking therapy aimed at changing behaviour patterns.  Practitioners often employ techniques such as bedtime restriction.  This works by looking at the time spent in bed versus the time spent asleep using a sleep diary and restricting the time allowed in bed to the time spent asleep (for example if someone’s diary indicates they spend 8 hours in bed but only 6 hours asleep they should only spend 6 hours in bed).  This is usually started as a trial for 2 weeks and can be a very simple yet effective way of managing the problem.  In fact, the evidence shows that cognitive behavioural interventions work better than sleeping tablets in most cases.

As I said at the beginning, problems with sleeping are common and there are a myriad of causes for them.  Reaching for sleeping tablets is rarely recommended and often employing some of the changes above can make a real difference to peoples quality of life.

About Blog

About Me

Me

 

I am an NHS GP with a specialist interest in Headache, who works in South London.  I have three major passions in my life: exercise (or “training” as we’re supposed to call it now), promoting health and well-being and my family.  To be a good and effective GP takes time and life experience: I know that the events in my life have shaped what kind of doctor I have become.

 

I have always been lucky to be relatively healthy and have never needed to spend any significant time in hospital aside from trips to asses minor sports injuries and one (humiliating) A&E visit during medical school (where my Mum mistook a migraine for meningitis).  Aside from migraines, my immediate family had also always been similarly healthy until the Summer of 2012.  I was in my second year of being a fully-fledged doctor and I was in my first proper GP placement.  I have to admit at the time I hated GP because I was not in a sociable practice: people tended to work in silos isolated from each other and I had next to no support, despite having very little experience of being a doctor.  In retrospect the work I was expected to do was alarming given the lack of knowledge I had at that stage of my training.  The saving grace was that I was that I was living at home so after hours of isolation (which sounds odd when you spend all day seeing patient after patient) and mentally taxing work, it was wonderful to be able to relax and spend time with my parents.

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One night in July, my Mum woke in the night with a bad migraine.  This wasn’t particularly unusual: she’d always suffered with bad migraines fairly frequently and wasn’t keen on taking any kind of preventative treatment because she thought they were a sign that she needed to rest so if she got rid of them how would she know something was wrong?  She had the usual flashing lights, unbearable pain and panic attack she experienced with her migraines.  Unusually though, this one carried on… and on… for 5 days.  And she was being sick a lot.  On the 5th day I was stumped: I knew I was out of my depth and I told her to call her GP.  He visited her and she called me at 2pm saying he’d called an ambulance for her to go to hospital.  He thought she’d picked up a stomach bug and was dehydrated.  He’d said her blood pressure was low (she said it usually was) and that she had a heart murmur… had she had one before?  She had when my sister was born and the scan had shown that everything was fine.  He thought it was best she went in for some fluids and to get it checked out and he’d see her in a few days.  As soon as she told me she was going to hospital I burst into tears.  I was “on-call” that afternoon until 6.30 and one of only two doctors in the surgery.  They wouldn’t be happy with me leaving but I knew I couldn’t work while my Mum was in A&E.

When I arrived, my Mum had been taken straight to resus: the bit we always see on casualty where all the “exciting” stuff happens.  I knew this meant she was very unwell.  My dad and I waited in the relatives room until the nurse came to update us.  He told us there’d been some “changes on the ECG”.  I cut in, “what changes?”  He paused and I explained I was an F2 and he told me there was “ST elevation”: she’d had a heart attack.  A bit later the consultant came to talk to us: she’d admitted to some mild aching in her chest when the “migraine” started but put it down to the panic she often felt during an attack.  The ECG and blood test confirmed she’d has a massive heart attack 5 days previously.  Her organs had started to shut down.  Had we thought about resuscitation?  This was a massive shock.  My sister rushed up from London and we all went to speak to her once they’d finished their tests: hours after she’d arrived.  She was very calm and we caught up on the information they’d given us.  She told us to take my Dad home because it was far too late for him to be out so we agreed.  But could I remember to cancel her massage and hair appointments on Tuesday?  Those were the last words she said to me.

Me and Mum
Me and Mum

This sudden turn of events when I was in my mid-twenties, and, in my opinion, far too young to lose a parent, completely changed my life.  For the first time I experienced symptoms of anxiety and panic at very inconvenient times and, looking back, I was definitely depressed for at least a year.  This is all normal in the context of what happened.  I was determined to take control of my own health and well-being.  I didn’t want to feel low any more and I didn’t want to suffer the same heart problems my Mum had either.  So I started exercising regularly (sometimes, arguably too regularly)… and I’ve been hooked ever since.

Me at KXU.jpeg

It’s also made me a better doctor.  I believe good health is far more than physical health (i.e. the absence of physical illness) but also ties in with emotional and psychological wellbeing; something which can easily be over-looked in an NHS under pressure.  Now more than ever, I think it’s vital that people (or “patients”) are empowered.  By that I mean have the knowledge and tools to cope with many of the health problems we all face day to day.  And that’s why I decided to write a blog…