Abstract
BackgroundRefractory migraine is a challenging condition with great impact on health related quality of life. Intravenous (IV) ketamine has been previously used to treat various refractory pain conditions. We present a series of patients with refractory migraine treated with intravenous ketamine in the hospital setting.MethodsBased on retrospective chart review, we identified six patients with refractory migraine admitted from 2010 through 2014 for treatment with intravenous ketamine. Ketamine was administered using a standard protocol starting with a dose of 0.1 mg/kg/hr and increased by 0.1 mg/kg/hr every 3 to 4 h as tolerated until the target pain score of 3/10 was achieved and maintained for at least 8 h. Visual Analogue Scale (VAS) scores at time of hospital admission were obtained as well as average baseline VAS scores prior to ketamine infusion. A phone interview was conducted for follow-up of migraine response in the 3 to 6 months following ketamine infusion.ResultsThe study sample had a median age of 36.5 years (range 29–54) and 83% were women. Pre-treatment pain scores ranged from 9 to 10. All patients achieved a target pain level of 3 or less for 8 h; the average ketamine infusion rate at target was 0.34 mg/kg/hour (range 0.12–0.42 mg/kg/hr). One patient reported a transient out-of-body hallucination following an increase in the infusion rate, which resolved after decreasing the rate. There were no other significant side effects.ConclusionIV ketamine was safely administered in the hospital setting to patients with refractory chronic migraine. Treatment was associated with short term improvement in pain severity in 6 of 6 patients with refractory chronic migraine. Prospective placebo-controlled trials are needed to assess short term and long-term efficacy of IV ketamine in refractory chronic migraine.Electronic supplementary materialThe online version of this article (doi:10.1186/s10194-016-0700-3) contains supplementary material, which is available to authorized users.
Highlights
Refractory migraine is a challenging condition with great impact on health related quality of life
Refractory migraine is included in ICHD-2 [10] and ICHD-3 beta [11] but criteria for intractable headache have only recently emerged [12]
Multiple treatment options have been proposed for management of refractory migraine including intravenous dihydroergotamine (DHE) and intravenous divalproex sodium [13, 14]
Summary
Refractory migraine is a challenging condition with great impact on health related quality of life. Intravenous (IV) ketamine has been previously used to treat various refractory pain conditions. We present a series of patients with refractory migraine treated with intravenous ketamine in the hospital setting. In the United States, chronic migraine prevalence is nearly 1% and results in enormous impact on headache-related disability, including higher Migraine Disability Assessment Test (MIDAS), reduced health-related quality of life (HRQoL), increased depression and anxiety (PHQ-4 and GAD-7 respectively), compared to episodic migraine [1,2,3,4,5,6]. Refractory migraine is included in ICHD-2 [10] and ICHD-3 beta [11] but criteria for intractable headache have only recently emerged [12]. Multiple treatment options have been proposed for management of refractory migraine including intravenous dihydroergotamine (DHE) and intravenous divalproex sodium [13, 14]
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