Management Of Headache Research Articles

Comparative study between different approaches for the management of postdural puncture headache

Introduction The postdural puncture headache (PDPH) is one of the spinal and epidural anesthesia complications. It can be induced by using large gauge-cutting needles or performing numerous trials. Conservative treatment was the primary option for the management of PDPH, sphenopalatine ganglion block (SPGB) can be a suitable and safe option for the treatment of PDPH. Aim The aim was to verify the efficacy and safety of transnasal SPGB using either lidocaine 2% or bupivacaine 0.5% as a treatment line for PDPH versus the conventional conservative treatment. Patients and methods In total, 120 patients with PDPH following cesarean section under spinal anesthesia were assigned and divided into three groups. Group L (n=40) received transnasal SPGB (lidocaine 2%), group B (n=40) received transnasal SPGB (bupivacaine 0.5%), and group C (n=40) received conservative treatment for 24 h [intravenous (IV) paracetamol 1 g/8 h]. The headache severity was measured by the visual analog scale (VAS) at 0 min, 30 min, 6 h, 12 h, and 24 h post treatment. Results No significant difference in the VAS from the baseline between the groups L and B was observed. VAS values were significantly lower in both groups when compared with patients in group C (P<0.05). No significant differences from baseline mean blood pressure, heart rate, or other complications (such as bleeding), were observed between the three groups at any timepoint. Conclusion The headache severity in PDPH cases might be reduced more efficiently through SPGB using either lidocaine or bupivacaine, unlike other conservative treatments such as paracetamol.

The teaching of headache medicine in France: A questionnaire-based study.

The treatment of patients with headache represents an important part of a neurologist's activity. It requires sufficient training for neurology residents. In France, residents in neurology can complete this training by attending specialized consultations or by participating in a postgraduate training program called "Diplôme Inter-Universitaire Migraine et Céphalées" (DIUMC). The objective of this cross-sectional study was to investigate the French residents' knowledge in headache medicine and the impact of different types of training in headache medicine that are available in France. An anonymous survey was carried out among 548 French residents in neurology. The questionnaires of 121 residents (22.1%) were analyzed. Among them, 54.5% (66/121) had no complementary training apart from the internship (Group 1), 21.5% (26/121) had attended only specialized consultations (Group 2), and 24% (29/121) had participated in the DIUMC (Group 3). There was no difference between all groups regarding the knowledge of the prevalence of primary or chronic headaches. There was almost no difference between the groups in the management of episodic migraine. In contrast, the management of tension-type headache and chronic headache was better known by residents of Group 3 than residents of Group 1. In these two diseases, residents of Group 3 offered prophylactic treatment more often. Almost 29% of the residents (35/121) had read the French guidelines for the diagnosis and management of migraine. In Group 3, residents had read them significantly more often (1.6% in Group 1, 38.5% in Group 2 and 62.1% in Group 3, p < 0.001). This study shows the lack of knowledge among French neurology residents regarding headache medicine. It highlights the interest of specific training programs that could improve the practical and theoretical knowledge of future neurologists.

Methylphenidate as a potential treatment for cluster headache

Cluster headache is a potentially debilitating condition that can lead to restrictions in occupational and day‐to‐day function. Here, the authors outline a case of a significant reduction in headache frequency in a patient who had an incomplete response to NICE‐recommended treatments, and was treated for attention deficit hyperactivity disorder with stimulant medications. This article builds on a small number of case reports indicating a potential role for stimulant medications such as methylphenidate in the management of cluster headache.

Narrative review of peripheral nerve blocks for the management of headache.

To provide an overview of the current available literature on peripheral nerve blocks for the management of migraine and other headache disorders in adults. Peripheral nerve blocks have been commonly performed in the headache practice for migraine, cluster headache, occipital neuralgia, and other headache disorders, despite a paucity of evidence supporting their use historically. In the past decade, there has been an effort to explore the efficacy and safety of peripheral nerve blocks for the management of headache, with the greatest interest centered around greater occipital blocks. We performed a search in PubMed using key words including "occipital nerve blocks," "peripheral nerve blocks," "occipital nerve," "migraine," "cluster headache," and "neuralgia." We reviewed the randomized controlled trials (RCTs), observational studies, and case series, and summarized the anatomy, techniques, and the evidence for the use of peripheral nerve blocks in different headache disorders, with particular focus on available RCTs. Case reports were included for a detail review of adverse events. Of 12 RCTs examining the use of greater occipital nerve blocks for migraine, all but one demonstrate efficacy with reduction in headache frequency, intensity, and/or duration compared to placebo. Studies have not demonstrated a difference in clinical outcomes with the use of corticosteroids for nerve blocks compared to blocks with local anesthetic in the treatment of migraine. There are two RCTs supporting the use of greater occipital blockade for cluster headache, both showing benefit of suboccipitally injected corticosteroid. One RCT suggests benefit of greater occipital nerve blocks for cervicogenic headache. Observational studies and case series/reports show that greater occipital nerve block may be effective in prolonged migraine aura, status migrainosus, post-dural puncture headache, and occipital neuralgia. Overall, peripheral nerve blocks are well tolerated. Serious side effects are rare but have been reported, including acute cerebellar syndrome and infection. Peripheral nerve blocks, especially occipital nerve blocks, are a viable treatment option for migraine and may be helpful in cluster headache as a transitional therapy or rescue therapy. Additional prospective studies are needed to investigate the efficacy and safety of occipital nerve blocks for long-term migraine prevention, as well as for other headache disorders, such as occipital neuralgia.

143 Understanding the Frequency of Emergency Department Utilization by Neurology Clinic Headache Patients Who Self-Report Visiting the Emergency Department for Headaches

Headache is the fourth most common cause of emergency department (ED) visits, compromising 1-3% of ED visits. The lifetime prevalence of headache occurrence is 17-25% in women and 6.5-9% in men. While chronic management of headaches is effective, it is significantly underutilized. Our outpatient neurology headache center collects patient-reported outcome (PRO) data for a variety of neurological conditions including headaches. One of the questions asks patient to self-identify their current ED utilization.

Migraine in physicians and final year medical students: A cross-sectional insight into prevalence, self-awareness, and knowledge from Pakistan.

BACKGROUNDDespite its high prevalence, migraine remains underdiagnosed worldwide. A significant reason is the knowledge gap in physicians regarding diagnostic criteria, clinical features, and other clinical aspects of migraine. AIMTo measure the knowledge deficit in physicians and medical students and to assess the prevalence of migraine in the same population.METHODSAn online questionnaire was developed and distributed among physicians and final year medical students on duty in various medical and surgical specialties of Allied and DHQ Hospitals, Faisalabad, between October 2018 and October 2019. Inclusion criteria were public practicing physicians who experience headaches, while those who never experienced headaches were excluded. Different questions assessed respondents on their knowledge of triggers, diagnosis, management, and prophylaxis of the migraine headache. They were asked to diagnose themselves using embedded ICHD-3 diagnostic criteria for different types of migraine. Graphs, tables, and figures were made using Microsoft Office 2016 and Microsoft Visio, and data analysis was done in R Studio 1.4.RESULTSWe had 213 respondents and 175 fulfilled inclusion criteria, with 99 (52%), 58 (30%) and 12 (6.3%) belonging to specialties of medicine, surgery, and others, respectively. Both genders were symmetrically represented (88 male and 87 female). Fifty-two (24.4%) of our 213 respondents were diagnosed with migraine, with 26 (50%) being aware of it. Females had higher prevalence among study participants (n = 28, 32.2%) compared to males (n = 20, 22.7%, P = 0.19). A majority (62%) of subjects never consulted any doctor for their headache. Similarly, a majority (62%) either never heard or did not remember the diagnostic criteria of migraine. Around 38% falsely believed that having any type of aura is essential for diagnosing migraine. The consultation rate was 37% (n = 65), and migraineurs were significantly more likely to have consulted a doctor, and a neurologist in particular (P < 0.001). Consulters and migraineurs fared better in the knowledge of diagnostic aspects of the disease than their counterparts. There was no significant difference in other knowledge aspects between consulters versus non-consulters and migraineurs versus non-migraineurs. CONCLUSIONCritical knowledge gaps exist between physicians and medical students, potentially contributing to misdiagnosis and mismanagement of migraine.

Factors associated with failed epidural blood patch after accidental dural puncture in obstetrics: a prospective, multicentre, international cohort study

BackgroundEpidural blood patch is commonly used for management of post-dural puncture headache after accidental dural puncture. The primary aim was to determine factors associated with failed epidural blood patch. MethodsIn this prospective, multicentre, international cohort study, parturients ≥18 yr receiving an epidural blood patch for treatment of post-dural puncture headache were included. Failed epidural blood patch was defined as headache intensity numeric rating scale (NRS) score ≥7 in the upright position at 4, 24, or 48 h, or the need for a second epidural blood patch, and complete success by NRS=0 at 0–48 h after epidural blood patch. All others were considered partial success. Multinominal logistic regression was used for statistical analyses with P<0.01 considered statistically significant. ResultsIn all, 643 women received an epidural blood patch. Complete data to classify failure were available in 591 (91.9%) women. Failed epidural blood patch occurred in 167 (28.3%) patients; 195 (33.0%) were completely successful and 229 (38.7%) partially successful. A total of 126 women (19.8%) received a second epidural blood patch. A statistically significant association with failure was observed in patients with a history of migraine, when the accidental dural puncture occurred between lumbar levels L1/L3 compared with L3/L5 and when epidural blood patch was performed <48 h compared with ≥48 h after accidental dural puncture. In patients having radiological investigations, three intracranial bleeds were diagnosed. ConclusionsFailed epidural blood patch occurred in 28.3% of women. Independent modifiable factors associated with failure were higher lumbar level of accidental dural puncture and short interval between accidental dural puncture and epidural blood patch. A history of migraine was associated with a higher risk of second epidural blood patch. Clinical trial registrationNCT02362828.

New-onset headache after percutaneous atrial septal defect closure.

Percutaneous closure of atrial septal defect (ASD) is a well-established procedure both in children and adults with very good long-term outcomes. Migraine headache (MHA) can be precipitated after ASD device closure and the mechanism is not fully understood. We reviewed medical records of all patients undergoing ASD device closure from January 2015 to January 2021 for new onset headache after the procedure. Diagnosis of migraine was established by guidelines of the International Headache Society. Out of 325 patients undergoing ASD device closure, five patients (1.5%) of various age groups (range 3.5-35 years) complained of severe migraine-like headaches within 2 weeks of the procedure. MHA was reported exclusively by females. All the patients were treated with oral paracetamol for the management of headaches. Three of 5 (60%) patients had a positive family history of migraine. Three patients reported complete disappearance of symptoms within 4-6 months. While two others (40%) had ongoing symptoms at 6 months follow-up. MHA can be precipitated after ASD device closure. The risk is specifically high in females with a family history of migraine. Dual antiplatelet drugs for the first 3 months after device closure may prevent such episodes. Prospective studies are needed to establish the universal role of dual antiplatelet drugs after ASD device closure.

Increasing Collaboration between Headache Medicine and Plastic Surgery in the Surgical Management of Chronic Headache.

Introduction:Chronic headache is one of the most disabling conditions afflicting humankind. The management of chronic headaches has, to date, been only partially successful. The goal of this paper is to highlight the importance of collaboration between surgeons and headache physicians in treating this condition.Methods:We present a narrative review of migraine pathophysiology, its medical and surgical treatment options, and the important role of collaboration between headache physicians and surgeons.Results:Migraine headaches can be treated with both medication-based regimens and surgery. Novel medications such monoclonal antibodies directed at the CGRP molecule or its receptor have recently been FDA approved as an effective treatment modality in chronic migraines. However, these medications are associated with a high cost, and there is a paucity in data regarding effectiveness compared to other treatment modalities. The pathophysiology of headache likely exists along a spectrum with peripheral — extracranial and meningeal — factors at one end and central — brain — factors at the other, with anatomic and physiologic connections between both ends. Recent evidence has clearly shown that surgical decompression of extracranial nerves improves headache outcomes. However, appropriate patient selection and preoperative diagnosis are of paramount importance to achieve excellent outcomes.Conclusions:Surgeons and headache physicians who are interested in providing treatment for patients with chronic headache should strive to form a close collaboration with each other in order to provide the optimal plan for migraine/headache patients.

Migraine: An Underestimated Neurological Condition Affecting Billions.

The second most prevalent cause of years of disability worldwide is migraine, a neurological condition that causes a persistent headache that is lifelong. This condition affects more than a billion people globally. Its widespread prevalence and concomitant impairment have several adverse effects. Migraines are brought on by numerous behavioural, ecological, and genetic factors. There are various types of migraines, of which migraine without aura is the most common. The objective of this article is to determine the causes of migraine headaches, review the appropriate diagnosis of migraine, and describe the migraine headache management alternatives that are available. Various treatments for migraine are available on the market. Among the many types of headaches, migraines are neurological in nature and are inherited in some people. It has four phases: prodromal phase, aura, attack phase, and postdrome phase. Stress, anxiety, changes in the female endocrine system, bright lights, loud noises, foul odour, excessive or insufficient sleep, changes in the environment or the climate, flashes of light or intense lighting, overexertion, missing meals, drinking alcohol and smoking, quitting caffeine, and taking too many migraine drugs are some of the triggering factors for migraine. Diagnosis of migraine mainly relies on a good history. Appropriate prevention can be done for specific indications. Treatment mainly revolves around medications like analgesics, triptans, ergot derivatives, and newly derived biologics. Lifestyle modifications are also essential as many daily life factors contribute to migraine. Migraine can be well-managed if sufficient attention and care are given along with proper medications and guidance. The patient should not ignore symptoms and report to the physician at the earliest so that correct management can be done.

Designing and In Vitro Characterization of pH-Sensitive Aspartic Acid-Graft-Poly(Acrylic Acid) Hydrogels as Controlled Drug Carriers.

Acetaminophen is an odorless and white crystalline powder drug, used in the management of fever, pain, and headache. The half-life of acetaminophen is very short; thus, multiple intakes of acetaminophen are needed in a day to maintain a constant pharmacological action for an extended period of time. Certain severe adverse effects are produced due to the frequent intake of acetaminophen, especially hepatotoxicity and skin rashes. Therefore, a drug carrier system is needed which not only prolongs the release of acetaminophen, but also enhances the patient compliance. Therefore, the authors prepared novel aspartic acid-graft-poly(acrylic acid) hydrogels for the controlled release of acetaminophen. The novelty of the prepared hydrogels is based on the incorporation of pH-sensitive monomer acrylic acid with polymer aspartic acid in the presence of ethylene glycol dimethacrylate. Due to the pH-sensitive nature, the release of acetaminophen was prolonged for an extended period of time by the developed hydrogels. Hence, a series of studies was carried out for the formulated hydrogels including sol-gel fraction, FTIR, dynamic swelling, polymer volume analysis, thermal analysis, percent porosity, SEM, in vitro drug release studies, and PXRD analysis. FTIR analysis confirmed the grafting of acrylic acid onto the backbone of aspartic acid and revealed the development of hydrogels. The thermal studies revealed the high thermal stability of the fabricated hydrogels as compared to pure aspartic acid. An irregular surface with a few pores was indicated by SEM. PXRD revealed the amorphous state of the developed hydrogels and confirmed the reduction in the crystallinity of the unreacted aspartic acid by the formulated hydrogels. An increase in gel fraction was observed with the increasing concentration of aspartic acid, acrylic acid, and ethylene glycol dimethacrylate due to the availability of a high amount of free radicals. The porosity study was influenced by the various compositions of developed hydrogels. Porosity was increased due to the enhancement in the concentrations of aspartic acid and acrylic acid, whereas it decreased with the increase in ethylene glycol dimethacrylate concentration. Similarly, the pH-responsive properties of hydrogels were evaluated by dynamic swelling and in vitro drug release studies at two different pH levels (1.2 and 7.4), and a greater dynamic swelling and acetaminophen release were exhibited at pH 7.4 as compared to pH 1.2. An increase in swelling, drug loading, and drug release was seen with the increased incorporation of aspartic acid and acrylic acid, whereas a decrease was detected with the increase in the concentration of ethylene glycol dimethacrylate. Conclusively, the formulated aspartic acid-based hydrogels could be employed as a suitable nonactive pharmaceutical ingredient for the controlled delivery of acetaminophen.

Osteopathic Manipulative Treatment and the Management of Headaches: A Scoping Review.

Headaches have been studied and treated since nearly 7,000 BC because of their significant global impact. Current headache treatment modalities are various and have a wide variety of targets, but medications are the most common. Since conventional medical treatments have several side effects, alternative remedies such as osteopathic manipulative treatment (OMT) should be considered. OMT can assist in the management of various health conditions, such as low back pain, neck pain, and headaches. The purpose of this scoping review is to evaluate recent findings regarding the efficacy of OMT modalities in the management of headaches such as tension-type headaches (TTH) and migraines.This study was designed as a scoping review to gather evidence on the efficacy of OMT modalities in the management of headaches. Following PRISMA guidelines, four databases were used to search for articles published between 2010 and 2022 that reported the use of OMT and manual therapy for TTH and migraines. Databases used include Embase, PubMed, Medline, and Web of Science. The following keywords were used: treatment, therapy, Headache, migraine, craniosacral, muscle energy, myofascial release, trigger point, osteopathic, and manipulation. The initial search yielded 473 unique articles after removing duplicates. After screening based on the inclusion and exclusion criteria, and after further analysis, 15 articles were selected.Data reports of OMT and manual therapy efficacy and/or effectiveness in treating TTH and migraine were analyzed. Articles included were randomized control studies (13 of 15, 86.6%), one pilot study (one of 15, 6.7%), and one case series (one of 15, 6.7%), which were divided into TTH (nine of 15, 60%) and Migraine Headaches (six of 15, 40%). All articles reported significant headache improvement in at least one measurement. Of all treatments analyzed, single technique interventions (seven of 15, 47%) and multiple technique interventions (eight of 15, 53%) were identified. Among the techniques used, Myofascial Release was the most common (nine of 15, 60%).The articles presented provide evidence of the significant benefits of manual therapy. Because of the limitations of traditional medicine, OMT can be used either as an alternative or adjuvant therapy for headaches. Evidence suggests the positive impact it can provide on headache management, but the number of randomized control trials and population samples should be increased to support its recommendation. This demonstrates how different osteopathic techniques can provide therapeutic effects on TTH, MH, and potentially other types of headaches. A preference for myofascial release was observed, which can be due to the fast relief from the physiologic effect on tissue movement.This review study demonstrates the benefits OMT has on decreasing headache frequency, intensity, and duration in TTH and migraines. OMT has shown to be beneficial, especially for patients seeking alternative non-pharmaceutical and non-invasive treatments. Further studies are needed to evaluate the effects of different OMT techniques, and different combinations of treatments, on other types of headaches.

Sphenopalatine Ganglion Block versus Conservative Management for Post Dural Puncture Headache in Cesarean Section

Introduction: Post-dural puncture headache is one of the frequently encountered and inevitable post-operative complications of the subarachnoid block. The primary treatment is always considered conservative management in such instances. However, an epidural blood patch remains an invasive gold standard treatment. Sphenopalatine ganglion block is propounded as minimally invasive with prompt and better outcomes. Objective: To assess the efficacy of Sphenopalatine ganglion block (SPGB) when compared to conservative management based on the onset of analgesia and its duration. Methods: This is a prospective study performed on 40 obstetrics patients who underwent Lower segment cesarean section in Lumbini Medical College and Teaching Hospital (LMCTH) who complained of Post dural puncture headache within 7 days. All the parturients are categorized into Group A, those who are treated with sphenopalatine ganglion block, and Group B, where post-dural puncture headache was treated with conservative management. Independent t-tests and Fischer’s test were used for statistical analysis. Results: The patients in group A showed positive outcomes where all of them were relieved of post-dural puncture headache within 10 mins after Sphenopalatine ganglion block (p&lt;0.001) and the mean pain score, based on a numerical pain rating scale was less or equal to 4 for the first 8 hours. Conclusions: Sphenopalatine ganglion block (SPGB) could be used as an effective first-line treatment modality in the management of post-dural puncture headache compared to conservative management.

Acute Headache Management for Patients with Subarachnoid Hemorrhage: An International Survey of Health Care Providers.

Severe headaches are common after subarachnoid hemorrhage. Guidelines recommend treatment with acetaminophen and opioids, but patient data show that headaches often persist despite multimodal treatment approaches. Considering an overall slim body of data for a common complaint affecting patients with SAH during their intensive care stay, we set out to assess practice patterns in headache management among clinicians who treat patients with SAH. We conducted an international cross-sectional study through a 37-question Web-based survey distributed to members of five professional societies relevant to intensive and neurocritical care from November 2021 to January 2022. Responses were characterized through descriptive analyses. Fisher's exact test was used to test associations. Of 516 respondents, 329 of 497 (66%) were from North America and 121 of 497 (24%) from Europe. Of 435 respondents, 379 (87%) reported headache as a major management concern for patients with SAH. Intensive care teams were primarily responsible for analgesia during hospitalization (249 of 435, 57%), whereas responsibility shifted to neurosurgery at discharge (233 of 501, 47%). Most used medications were acetaminophen (90%), opioids (66%), corticosteroids (28%), and antiseizure medications (28%). Opioids or medication combinations including opioids were most frequently perceived as most effective by 169 of 433 respondents (39%, predominantly intensivists), followed by corticosteroids or combinations with corticosteroids (96 of 433, 22%, predominantly neurologists). Of medications prescribed at discharge, acetaminophen was most common (303 of 381, 80%), followed by opioids (175 of 381, 46%) and antiseizure medications (173 of 381, 45%). Opioids during hospitalization were significantly more prescribed by intensivists, by providers managing higher numbers of patients with SAH, and in Europe. At discharge, opioids were more frequently prescribed in North America. Of 435 respondents, 299 (69%) indicated no change in prescription practice of opioids with the opioid crisis. Additional differences in prescription patterns between continents and providers and while inpatient versus at discharge were found. Post-SAH headache in the intensive care setting is a major clinical concern. Analgesia heavily relies on opioids both in use and in perception of efficacy, with no reported change in prescription patterns for opioids for most providers despite the significant drawbacks of opioids. Responsibility for analgesia shifts between hospitalization and discharge. International and provider-related differences are evident. Novel treatment strategies and alignment of prescription between providers are urgently needed.

AKT answer relating to management of headache

AKT answer relating to management of headache

AKT question relating to management of headache

AKT question relating to management of headache

Student pharmacist characteristics and management of headache

IntroductionHeadache is a prevalent, debilitating condition that affects 50% of adults globally. Little is known about headache among student pharmacists. This study describes the characteristics and management of headache among student pharmacists as well as implications for pharmacy education. MethodsData were collected on headache characteristics, symptoms, triggers, impact, and pharmacological and non-pharmacological management strategies using an online questionnaire sent to all student pharmacists at one United States college of pharmacy in April 2021. Students who completed the questionnaire and reported having headache were included. Data were compared between graduating class years using chi-square and Kruskall-Wallis tests as appropriate. ResultsA total of 111 students were included in the study. The most commonly reported headache characteristics were throbbing and pressure-like, moderate intensity, and < four hours duration. The most common symptoms were neck or shoulder pain and mood or personality changes. The strongest headache trigger was sleep quantity. The most commonly used pharmacologic strategy was caffeine, and the most commonly used non-pharmacologic strategies were rest or sleep and drinking water. There were no significant differences between graduating class years for any variable except amount of screen time. ConclusionsStudent pharmacists with headache in this study had characteristics, symptoms, and triggers of headaches in keeping with existing knowledge and used a variety of pharmacological and non-pharmacological pain management strategies. Headache posed a burden for students, suggesting there may be a need for greater student support despite their perception that headache had a low impact on their grades.

Can flunarizine be used routinely as the first option for childhood headache treatment?: Flunarizine and childhood headache.

The prevalence of headache in childhood increases due to environmental factors. Various risk factors in children whose playgrounds are restricted outside and therefore remain inactive. So diagnosis and treatment can be challenging. The aim of this study was to evaluate the experience of flunarizine in childhood headache with a focus on efficacy and success. We conducted a retrospective observational study of 185 pediatric patients at the tertiary pediatric emergency and pediatric neurology unit between May 2018 and May 2020. Patients with headache for >15 days of a month for at least 3 months were included in the study, whether or not receiving treatment. Also, all patients who had an adequate follow-up period were included in the study. All patients were evaluated by history, physical-neurological examination, blood tests, blood pressure, eye examination, and cranial magnetic resonance imaging. All data were evaluated statistically. Ninety-eight (53%) of 185 cases were female and 87 (47%) were male. Average age was 11.4 years (min-max, 4-17). There was family history in 51.3% of the cases. The most frequent applicants were in the autumn season (43%), when schools were opened. Organic causes were hypertension in 1 case, brain tumor in 1 case, and papilledema due to idiopathic intracranial hypertension in 2 cases. The other cases were asked to make a 1-month pain chart and grading according to the visual analog scale. In this process, it was stated that painkillers could be used if needed. At the end of the first month, these patients were reevaluated. Flunarizine treatment was initiated in 95 patients who had to use painkillers for >4 times and who described ≥6 pain score according to the visual analog scale. The treatment was discontinued due to sleepiness and weakness in 2 patients. At the end of the third month, a 50% reduction in headache was observed in 82 cases (86.3%). We used flunarizine as the first choice in all patients and we achieved a high rate of treatment success. Flunarizine can be considered as an alternative option for headache management in terms of low side effects, easy accessibility, and compliance with treatment.

Comparison of Sphenopalatine Block and Intravenous Paracetamol for the Treatment of Post-Dural Puncture Headache

Objective: To compare the effect of topical sphenopalatine block and intra venous Paracetamol in the management of post-Dural puncture headache.&#x0D; Study Design: Quasi-experimental study.&#x0D; Place and Duration of Study: Combined Military Hospital Peshawar Pakistan, from Jan to Aug 2021.&#x0D; Methodology: This experimental study was conducted on 153 patients who underwent lumbar puncture for any procedure and then suffered from post-Dural puncture headaches. Patients were randomized into two groups. Group A received the topical sphenopalatine block, while group B received the intravenous Paracetamol three doses 12 hours apart. Headache was recorded on Numeric pain score (NPS) 24 hours after the surgical procedure. Comparison in pain relief was compared in both groups at 1 hour, 12 hours, 24 hours and 48 hours.&#x0D; Results: Out of 153 patients randomized into two groups, 76 (49.7%) were categorized into Group-A, and 77 (50.3%) were categorized into Group-B. 63 (41.2%) were male, while 90 (58.8%) were female. The mean age of patients included in our study was 34.34 ± 4.33 years. Gynaecological/obstetric procedures 70 (45.7%) were the most common indication for lumbar puncture in our study. At 1, 12, 24 and 48 hours, pain relief was statistically significantly better in Group-A than in Group-B (p- value&lt;0.005).&#x0D; Conclusion: Sphenopalatine ganglionic block emerged as a better option for pain relief among patients suffering from post-Dural puncture headache than intravenous Paracetamol. In addition, immediate and short-term relief was better among patients who used sphenopalatine block.

Efficacy of cryoneurolysis in the management of chronic non-cancer pain: A systematic review and meta-analysis.

Background and Aims:Cryoneurolysis, a neuroablative technique, is used in the event of failure of conservative treatment in chronic pain conditions. To date, no systematic review has been published to demonstrate its effectiveness in managing chronic non-cancer pain. Therefore, this review was done to ascertain the efficacy of cryoneurolysis and describe its role in chronic non-cancer pain management.Methods:We searched PubMed, Cochrane, Embase, Scopus, and Google Scholar databases for articles published between January 2011 and September 2021. Two independent reviewers extracted the data from the included studies. Assessment of risk of bias of included randomised controlled trials (RCTs) was done using RevMan 5.4.1 software and Newcastle-Ottawa scale was used for non-randomised studies.Results:Ten studies enroling a total of 425 patients were included in the qualitative analysis. Eight studies were assessed quantitatively. RCTs were found only for cervicogenic headache and knee osteoarthritis management. The rest of the included studies were prospective non-controlled and retrospective studies. A significant pain reduction was seen at seven-day [Standardised Mean Difference (SMD) 1.77 (1.07, 2.46)], P < 0.00001, I2 = 79%), one-month (SMD 3.26 [2.60, 3.92], P < 0.00001, I2 = 45%), three-month (SMD 2.58 [1.46, 3.70], P < 0.00001, I2 = 93%), six-month (SMD 2.38 [0.97, 3.79], P = 0.001, I2 = 86%) follow-ups. Improved disability and no serious complications were noted.Conclusion:Cryoneurolysis appeared to be effective in pain alleviation in refractory painful conditions for up to six months. It is safe and well-tolerated with an excellent safety profile but the quality of evidence is limited by substantial heterogeneity between trials. Therefore, more comparative clinical trials on a larger sample size are needed to provide more concrete evidence.