Marijuana is one of the most popular recreational drugs worldwide, and is the #1 illegal drug in the US (followed by cocaine). It is estimated that in the US, about 13.5% of the population uses it every year. (Zhang, 2019) As medical marijuana has become legal in many countries as well as about half of the states in the USA, it is now possible to discuss its use for treatment of common conditions such as dizziness, nausea and headache.
Cannabis is a generic term used for drugs produced from plants belong to the genus Cannabis (i.e. marijuana). Cannabis is not a single substance but rather is a mixture of up to roughly 60 compounds. Some of them, like THC (d-9-tetrahydrocannabinol), are psychoactive, and most others are not.
Prescription forms of cannabinoids include:
|Name||Constituents||FDA approval||Legal under federal/state laws|
|Marijuana||THC, CBD, others||No||No/Yes|
|Dronabinol (Marinol)||THC||Yes||yes/yes, was schedule I in 1971, but FDA indications suggest there i an accepted use.|
|Nabilone (Cesamet)||Synthetic cannabinoid||Yes||Yes/yes|
|Nabiximole (Sativex)||Oral spray mix of THC and CBD||No||No/no -- available as of 2015 only in FDA approved clinical trials|
According to Fife et al, Marijuana is a plant of the species Cannabis sativa or Cannabis indica, and contains many chemical compounds. THC is the chief psychoactive component, while CBD (cannabidiol) has minimal or no psychoactive effects. Other cannabinoids without psychoactive properties include cannabigerol and cannabinol. THC can be measured in the blood, while carboxy THC is detected only in the urine. Hemp, made from the stem of the plant, contains only traces of THC. There are several strains of cannabis, mainly differentiated by the their psychoactive properties. "sativa' is more stimulating. "indica" is more calming. "hemp" has low or absent THC.
A single dose of cannabis can be detected in the urine for 12 days. Thus someone who is involved in an auto-accident 10 days after using cannabis, could theoretically be cited for "DUI".
One would think that it might be possible to use a non-psychoactive cannabinoid for a medical purpose, without running into issues with mental status. Nevertheless, due to the odd status in the US where research on cannabis has been suppressed by the government, we know little about the non-psychoactive components of Marijuana. We do not know, for example, if they cause cancer (just an example).
Rather astoundingly, Cannabis appears to activate specific endocannabinoid receptors, mainly in the CNS. There are two main cannabinoid receptors, CB1 and CB2. According to Baron (2018), CB1 is found mainly in the CNS. CB2 is more numerous in the peripheral tissues.
THC (tetrahydrocannabinol) is a partial agonist of CB1 (more so than CB2).
Cannabidiol (CBD) has no psychoactive properties, does not attach to CB1 or CB2, but functions as a noncompetitive antagonist at CB1.
The details of what it does to the brain are being worked out and are presently the subject of considerable controversy. While there are claims that cannabis reduces cognitive function, a recent study published in JAMA psychiatry, analyzing 69 studies, suggested that there is only a very small effect after 72 hours (Scott et al, 2018)
As of 2015, Fife et al (2015) summarized their conclusions regarding utility of Cannabis in neurological disorders.
There was evidence for effectiveness in spasticity, central pain in MS. Nabiximols was thought to be "probably effective" in reducing bladder spasms (this drug is also used to treat nausea, see below). In movement disorders such as tremor, Huntington disease, and dopamine related dyskinesias, it was thought either ineffective or unknown. For Epilepsy, as of 2015, it was unknown.
THC (brand name Dronabinol) has been extensively studied with placebo controlled trials for nausea. A similar drug called Nabilone is also available. Both of these have been approved by the FDA for treatment of nausea and vomiting associated with chemotherapy. Another substance called "Nabiximol" is not currently FDA approved for nausea, but it is licensed in other countries and appears to be similar.
McGeeney (2012) suggests that anecdotal evidence suggests that they "are used" by patients for migraine, including as an abortive, and for cluster headache. Baron (2015) also suggests that there is some evidence for a good effect in migraine. As there is some evidence for an effect in chronic pain, one would anticipate a positive effect also in chronic migraine. Thus evidence is currently extremely weak.
According to Baron (2018), a chemical called anandamide inhibits dilation of blood vessels, modulates CGRP, and cortical spreading depression. CB1 also inhibits pain responses. We consider this also anecdotal.
There are presently (in 2015) no studies of cannabis for treatment of dizziness, and dizziness appears to be more of a side effect than a therapeutic target (Grotenhermen et al, 2012). Smith (2006) suggested that there are cannabinoid receptors in the central vestibular system. More studies are needed.
We have had heard from our patients that they have sometimes had a good response to a non-mind altering component of cannabis (CBD). In theory, this might be related to the anti-seizure effects of some components of cannabis. At this date (early 2018), these are just anecdotes.
Products that we have been told were helpful are "Charlotte's Web", "Watermelon Pucks", and "Anandahemp 200". The first is CBD oil, and can easily be ordered from the internet. The second contains some THC, and is not as readily available. As noted above, THC is approved by the FDA for treatment of nausea and vomiting associated with chemotherapy, and thus it is not surprising that "Watermelon Pucks" might be helpful in some people with dizziness. To be very clear, I am not advocating for these products, but I am simply transmitting what patients are telling me.
As of 2019, cannabis is scheduled to be available for recreational use by early 2020. Presently, In Illinois, the Illinois Compassionate Use of Medical Cannabis Pilot Program requires physicians to certify the diagnosis of a debilitating condition or terminal illness for a qualifying patient seeking to apply for a medical cannabis registry identification card. Whether or not a physician chooses to provide a written physician certification is up to the health care practitioner. More information is here: https://www.dph.illinois.gov/topics-services/prevention-wellness/medical-cannabis/physician-information
According to Fife et al (2015), the system used in Illinois is the usual one used to handle the odd situation where the Federal government states that licensed physicians cannot legally prescribe herbal marijuana (although they may prescribe nabilone or dronabinol). Physicians can document that the patient has a medical condition that justifies the use of marijuana under that state's law. Patients then may proceed to acquire the marijuana, under the particulars of the laws of their state. Nevertheless, certain institutions, including the Department of Veteran affairs, may have policies banning physicians from discussing medical marijuana with their patients.
Note that THC can be detected in the urine as long as 12 days after a single "dose". This means that in Illinois, should one be involved in an auto accident, it is theoretically possible to be cited for DUI, 12 days after ingesting a small amount of medical marijuana.
An individual diagnosed with one or more debilitating conditions is eligible to apply for a medical cannabis registry identification card. The qualifying patient must obtain a written certification from a physician specifying their debilitating condition, unless they are a veteran receiving health services at a VA facility. Veterans must submit one year of medical records from the VA facility where they receive services. Effective January 1, 2015, the Act was amended to include eligibility for children under age 18 and to add seizure disorders to the list of debilitating conditions. On June 30, 2016, the Act was amended (Public Act 099-0519) to add Post-Traumatic Stress Disorder (PTSD) as a debilitating condition and to allow persons diagnosed with a terminal illness to apply for a medical cannabis registry identification card. The Act is effective until Jan, 1, 2020.
Qualifying patients must be diagnosed with a debilitating condition, as defined in the Compassionate Use of Medical Cannabis Pilot Program Act, to be eligible for a medical cannabis registry identification card in Illinois.
On this list, conditions that might cause or be associated with dizziness include Arnold-Chiari, Cancer, Hydrocephalus, MS, myoclonus, and TBI. Neither migraine nor intractable nausea are included here.