Abstract
Background: The trigeminal ganglion plays a key role in primary headache pathophysiology. Calcitonin gene-related peptide (CGRP) and CGRP receptors are expressed in trigeminal neurons that form C-fibers and A-fibers, respectively. In migraine attacks, there is release of CGRP into the cranial venous outflow, in refractory headache to conventional pharmacologic management, minimally invasive techniques such as greater occipital nerve block (GONB) are feasible for pain relief, and help to decrease the frequency of the attacks, Studies on the ultrasound (US) guided GON injection technique have emphasized that this technique has a higher success rate and should allow for a more precise block of the nerve. Our study will be concerned by correlation of CGRP level as a biomarker for effectiveness and responders of us guided GON block in chronic migraine (CM). Methods: twenty patients diagnosed with chronic migraine were recruited in this study. All participants underwent ultrasound-guided bilat. GONB by 40 mg triamcinolone and 1 cc leidocaine using a portable ultrasound system with a 7 – 13 MHz multifrequency transducer, blood samples were collected from antecubital vein immediately before and three to five weeks after injection clinical response was evaluated using headache diaries Results: CGRP levels after ultrasound guided GONB (median, 40 pg/mL; range, 25-60) were significantly lower as compared with CGRP levels obtained before GONB (median, 145 pg/mL; range, 60-380; P =0.001). Pretreatment CGRP levels in non-responders (310 pg/mL) were significantly higher than those seen in responders being in poor responders less than 50% improvement (135 pg/ml) and good responders (140 pg/mL; P = 0.003). One month after treatment. A number of demographic factors, clinical features, and comorbidities were not different in responders as compared with those of nonresponders. Conclusion: These results suggests that interictal CGRP levels can be of help in predicting the response to GONB and suggest that the mechanism of action of GONB in CM is the reversal of sensitization as a result of the inhibition of CGRP release still more studies needed to highlight CGRP role with GONB
Highlights
Migraine is a common, multifactorial, neurovascular disorder with major individual and societal effects. ( Goadsby et al.,2011)Migraine affects roughly 15% of people and is typically characterised by disabling episodes of severe headache accompanied by nausea, vomiting, and hypersensitivity to light, sound, and smell for up to 3 days.( Olesen et al.,2013).In a third of patients, attacks might be associated with transient focal neurological aura symptoms; it has been suggested that migraine with and without aura are distinct disorders
CernudaMorollón, E. et al (2013) We show here that treatment with greater occipital nerve block (GONB) significantly decreases interictal Calcitonin gene-related peptide (CGRP) levels measured in peripheral blood samples in patients with chronic migraine (CM).These results contribute to clarifying the mechanism of action of GONB in CM and suggest that the measurement of interictal CGRP levels can be of help in predicting the response to GONB
On the other hand Bovim and Sand (1992) examined the diagnostic value In our study we found that 45% of the patients showed good response and effects of GON block and found only 6% in the migraine group,40% showed poor response and about 15% showed no response at all, here we show that CGRP levels are decreased after GONB, and that this reduction correlates with its efficacy rate
Summary
Multifactorial, neurovascular disorder with major individual and societal effects. ( Goadsby et al.,2011)Migraine affects roughly 15% of people and is typically characterised by disabling episodes of severe headache accompanied by nausea, vomiting, and hypersensitivity to light, sound, and smell for up to 3 days (migraine without aura).( Olesen et al.,2013).In a third of patients, attacks might be associated with transient focal neurological aura symptoms (migraine with aura); it has been suggested that migraine with and without aura are distinct disorders. Aura is most likely caused by cortical spreading depression, and headache by activation of the trigeminovascular system and associated release of CGRP. Migraine headache is caused by activation of the trigeminovascular system (TVS) The TVS consists of nociceptive trigeminal sensory afferents surrounding cranial blood vessels. Upon activation of these perivascular trigeminal afferents, the signal travels through the trigeminal ganglion to neurons in the trigeminocervical complex, using CGRP as the main neurotransmitter. There is release of CGRP into the cranial venous outflow, in refractory headache to conventional pharmacologic management, minimally invasive techniques such as greater occipital nerve block (GONB) are feasible for pain relief, and help to decrease the frequency of the attacks, Studies on the ultrasound (US) guided GON injection technique have emphasized that this technique has a higher success rate and should allow for a more precise block of the nerve. Our study will be concerned by correlation of CGRP level as a biomarker for effectiveness and responders of us guided GON block in chronic migraine (CM)
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