There are only two prospective trials containing a control group evaluating the use of cannabinoids in the treatment of headache disorders, specifically chronic migraine, cluster headache, and medication overuse headache. There are no placebo-controlled studies of cannabis for headache disorders, although a multicenter, double-blind, placebo-controlled study evaluating efficacy and safety of a synthetic Δ 9-tetrahydrocannabinol (THC), Dronabinol, in a metered dose inhaler for the treatment of migraine with and without aura has been completed, but results not available. At the time of this writing, the limited supporting headache literature consists of one retrospective analysis, numerous case series, case studies, and case reports, clinical/anecdotal reports, and surveys. Publications detailing this headache, migraine, and facial pain literature, as well as described mechanisms of pain relief with cannabis and cannabinoids are available and should be reviewed, but are beyond the scope of this paper. Supporting evidence also exists for cannabis/cannabinoids in the treatment of migraine and/or chronic migraine, cluster headache, chronic headaches, medication overuse headache, idiopathic intracranial hypertension, and multiple sclerosis associated trigeminal neuralgia. However, most of these registries do not further differentiate chronic pain into different pain subsets. Most medicinal cannabis registries report that chronic pain is the most common indication for use. In 2014, the Canadian Pain Society revised their consensus statement to recommend cannabinoids as a third-level therapy for chronic neuropathic pain given the evidence of cannabinoid efficacy in the treatment of pain with a combined number needed to treat (NNT) of 3.4. In 2017, The National Academies of Sciences, Engineering, and Medicine published a statement that the use of cannabis for the treatment of pain is supported by well-controlled clinical trials and that there is substantial evidence that cannabis is an effective treatment for chronic pain in adults. The use of medicinal cannabis for a multitude of health maladies, particularly chronic pain, has been well described through ancient, historical, and current times, and well supported through the medical literature. At the time of this writing, there are currently 29 states which have legalized medicinal cannabis, 9 states and Washington DC which have legalized both medicinal and recreational cannabis use, and 18 states which have legalized cannabidiol (CBD)-only bills. The legal use of medicinal cannabis continues to increase globally, including the United States. Prospective studies are needed, but results may provide early insight into optimizing crossbred cannabis strains, synergistic biochemical profiles, dosing, and patterns of use in the treatment of headache, migraine, and chronic pain syndromes. Opiates/opioids were most commonly substituted with cannabis. This could reflect the potent analgesic, anti-inflammatory, and anti-emetic properties of THC, with anti-inflammatory and analgesic properties of β-caryophyllene and β-myrcene. Hybrid strains were preferred in ID Migraine™, headache, and most pain groups, with “OG Shark”, a high THC (Δ9-tetrahydrocannabinol)/THCA (tetrahydrocannabinolic acid), low CBD (cannabidiol)/CBDA (cannabidiolic acid), strain with predominant terpenes β-caryophyllene and β-myrcene, most preferred in the headache and ID Migraine™ groups. The majority of headache patients treating with cannabis were positive for migraine. Prescription substitution in headache patients included opiates/opioids (43.4%), anti-depressant/anti-anxiety (39%), NSAIDs (21%), triptans (8.1%), anti-convulsants (7.7%), muscle relaxers (7%), ergots (0.4%).Ĭhronic pain was the most common reason for cannabis use, consistent with most registries. Many pain patients substituted prescription medications with cannabis (41.2–59.5%), most commonly opiates/opioids (40.5–72.8%). Hybrid strains were most preferred across all pain subtypes, with “OG Shark” the most preferred strain in the ID Migraine™ and headache groups. Therefore, 88% ( n = 445) of headache patients were treating probable migraine with cannabis. These patients were given the ID Migraine™ questionnaire, with 68% ( n = 343) giving 3 “Yes” responses, 20% ( n = 102) giving 2 “Yes” responses (97% and 93% probability of migraine, respectively). Across all 21 illnesses, headache was a symptom treated with cannabis in 24.9% ( n = 505). Of 2032 patients, 21 illnesses were treated with cannabis.
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