Intractable Migraine Headaches Research Articles

Reactivation of Herpes Simplex Virus Following Sphenopalatine Ganglion Nerve Block: Case Report and Review of the Literature.

A 36-year-old woman with no significant past medical history underwent a sphenopalatine ganglion block for treatment of a month-long migraine headache refractory to conservative treatment protocols. The headache resolved initially, but 1 day following the procedure, the headache recurred. The patient also developed an erythematous and edematous rash which cultures confirmed to be herpes simplex virus (HSV). Following several unsuccessful treatment modalities, the patient received valacyclovir, which resulted in resolution of her headache. Underlying HSV-1 infection may cause intractable migraine headache and nerve blocks may potentiate reactivation of latent HSV infection that caused the skin lesion in this case.

Neurosarcoidosis in a young male presenting with intractable migraines, blurry vision, and other nonspecific neurological symptoms case report

BackgroundNeurosarcoidosis can have various neurological outcomes and presentations. It is an uncommon diagnosis, especially in young Caucasian males presenting with predominantly migraine headaches.Case presentationA Caucasian male in his 20s with no medical history presented with 1 month of intractable migraine headaches associated with left sided blurry vision, nausea and vomiting. He has also been having intermittent paresthesia’s in the left upper extremity. He reports lightheadedness when moving from sitting to standing and occasionally feels unsteady on his feet. He also endorses night sweats, generalized malaise, and fatigue. On admission, CT chest, abdomen, and pelvis showed diffuse lymphadenopathy above and below the diaphragm, as well as widespread pulmonary nodules. MR head and spine showed multiple and diffuse nodular leptomeningeal enhancements and enhancement foci along the cervical, thoracic, and lumbar spine. Lumbar puncture showed elevated total nucleated cells and protein. Surgical pathology from a right inguinal lymph node showed many scattered multinucleated giant cells and epithelioid histiocytes consistent with non-necrotizing granulomas seen in sarcoidosis. He was treated with high dose steroids with significant improvement in symptoms.ConclusionsThe diagnosis of neurosarcoidosis may be challenging, and the differential may include other infectious, neoplastic, and inflammatory conditions. Neurosarcoidosis may present in a young Caucasian male with a constellation of nonspecific neurological symptoms such as cranial nerve palsies, gait imbalance, paresthesia’s, and headaches, among other presentations. Neurosarcoidosis may present similarly to lymphoma with constitutional symptoms of night sweats, fatigue, as well as widespread lymphadenopathy. Histopathology may be useful in diagnosis. Neurosarcoidosis may initially respond well to steroid treatment.

Mega-Dose Dietary Riboflavin in Treatment in Keratoconus, Post-Refractive Cornea Ectasia and Migraine. Has Its Time Arrived

Recently, several studies and investigators have shown the beneficial effects of high dose dietary riboflavin (vitaminB2) in the treatment of keratoconus, post-refractive(LASIK, PRK & Radial Keratotomy) ectasia (with sunlight exposure) and patients treated with our own protocol(NIH Clinical Study – www.clinicaltrials.gov - # NCT03095235) discovered significant relief for intractable migraine headaches and/or ophthalmic migraine (classic migraine visual symptoms without headache).

Occipital Nerve Stimulation and Sphenopalatine Ganglion Stimulation for Treatment of Intractable Headache Syndromes.

Headaches are an increasing cause of disability in the world. Intractable headache syndromes affect all age groups but predominantly the middle-aged, working population. Occipital neuralgia is a frequent comorbidity with intractable migraine headaches. Occipital nerve stimulation at the level of nuchal ridge is a reasonable option for these refractory patients. Ultrasound guidance of occipital nerve stimulation can optimize depth placement of leads. Revision surgeries of occipital nerve stimulation are usually performed using surgical leads. Cluster headaches and trigeminal autonomic cephalagias (TACs) are refractory headache conditions that are mediated by sphenopalatine ganglion. Sphenopalatine ganglion stimulation with infrazygomatic approach and fluoroscopic guidance of percutaneous leads can help alleviate pain from cluster headaches and TACs. Innovation in neurostimulation technologies have brought new optimism to these refractory conditions. Efficient and optimal delivery of neurostimulation for intractable headache syndromes requires a multidisciplinary team-based approach for long term compliance and efficacy.

Improvement of refractory migraine headache by propofol: case series

BackgroundSeveral studies have been conducted on managing migraine headaches and developing effective medications for decreasing migraine-associated pain.Case presentationIntravenous propofol was prescribed (10 mg every 5 min) for eight patients with intractable migraine headaches visiting the Emergency Department. The average pain score experienced by patients was recorded using the Visual Analogue Scale at the beginning of the treatment procedure and following the injection for 30 min (5-min intervals). The patients’ reported pain scores decreased significantly (P = 0.01) from 8.87 ± 0.83 (CI: 8.17, 9.57) to 1.12 ± 0.83 (CI: 0.43, 1.82) before and 30 min following the injection.DiscussionIt seems that in the treatment of intractable migraine headaches, GABAergic receptors, compared to the normal conditions, have a lower activity status.ConclusionBecause of the high tendency of propofol to GABAergic receptors, it probably changes this physiological condition by activating the receptors, which results in a significant pain reduction.

Pancytopenia Secondary to Cyclophosphamide in a Case of Factitious Breast Cancer

To the Editor: Reports of factitious symptoms have peppered the clinical literature since Dr Richard Asher’s initial identification and description of Munchausen’s syndrome in 1951.1 However, factitious symptoms may now be potentially groomed through the Internet, which not only offers endless information about medical symptoms but also enables access to non-supervised treatment. The following case demonstrates the ease with which patients can obtain and distort medical information as well as order potent medications online—and the harm that can ensue. Case report. Ms A, a 29-year-old white woman, was admitted to an acute-care hospital through the emergency department in 2010 for pancytopenia. She reported a history of stage 1, estrogen-positive breast cancer and was receiving cyclophosphamide therapy. The pancytopenia was initially discovered during routine blood work that was obtained prior to a dental procedure for an abscessed tooth. The patient was later directed to our emergency department for further evaluation. At the time of admission to hospital, the patient’s white blood cell count was 0.1 cells/mL, hemoglobin was 6.4 g/dL, hematocrit was 17.9%, and platelets were 2 × 109/L. Following laboratory confirmation, the patient was admitted to the intensive care unit (ICU) under neutropenic precautions. The cyclophosphamide was discontinued, and the patient was transfused with packed red blood cells and granulocyte colony-stimulating factor. In an attempt to gather additional information through medical records, we asked the patient about her current providers and received the names of several treating physicians as well as contradictory information regarding her treatment. Ultimately, all of the physicians whom the patient named as part of her treatment team denied seeing her as a patient. When confronted with this conflicting information, the patient admitted that she had diagnosed herself with breast cancer based upon a family history of breast cancer and assessment on an Internet breast-cancer risk-factor calculator. After personally concluding that she had breast cancer, the patient ordered cyclophosphamide online from a Web site based in India. At no time did she provide any reason or goal in attempting to deceive the treating medical team with regard to her alleged cancer. Further background investigation revealed that the patient had previous hospital admissions for intractable migraine headaches that included evaluation by magnetic resonance imaging, magnetic resonance angiography, magnetic resonance venography, and lumbar puncture—none of which revealed any abnormalities. Once the patient’s pancytopenia resolved, she was transferred from the ICU to a standard medical floor, where she developed unexplained hematomas on the left arm and right leg. Once the hematomas resolved, a psychiatry consultation was requested and the patient was transferred to the inpatient psychiatry unit with a DSM-IV diagnosis of factitious disorder with predominantly physical signs and symptoms. On the day of her transfer, the patient was sent to the emergency department for self-reported hematuria; urinalysis in the emergency department revealed no abnormalities. Although there is a previous case in which a patient feigned ovarian cancer by obtaining symptoms through online information2 and a second case in which a patient underwent bilateral mastectomies for self-reported breast cancer,3 there is no previously reported case in which a patient became cytopenic due to self-purchased chemotherapy for self-diagnosed breast cancer. Clearly, factitious medical disorders can take a number of dangerous forms when aided by the Internet.

Propofol hemisuccinate suppresses cortical spreading depression

Propofol is a rapidly acting water-insoluble non-barbiturate anesthetic agent that is widely used as an intravenous sedative–hypnotic agent. Anecdotal evidence indicates that propofol may be effective at terminating intractable migraine headache. Cortical spreading depression (CSD) is believed to be the neural correlate of migraine aura and may be a trigger for migraine pain. Agents that block the induction or slow the spread of CSD may be of utility in treating migraine. Here we examined the ability of propofol hemisuccinate (PHS), a water-soluble prodrug of propofol, to affect CSD in mice. For comparison, we examinined dizocilpine, an NMDA receptor antagonist, that is well recognized to inhibit CSD. When administered 15min prior to activation of CSD by KCl application to the cortex, intraperitoneal PHS at doses of 120 and 200mg/kg decreased the number of CSD deflections without an effect on CSD amplitude, and at 200mg/kg caused a 77% reduction in CSD velocity. The minimally-effective dose of PHS (120mg/kg) did not cause sedation or motor impairment and while some animals receiving 200mg/kg did demonstrate motor impariment none exhibited loss-of-righting reflex (anesthesia). Dizocilpine produced comparable inhibition of CSD at doses of 0.5 and 2.5mg/kg. We conclude that acute PHS treatment inhibits CSD. Our results indicate that propofol, or its prodrug PHS, are worthy of further investigation as a treatment for migraine.

Peripheral Nerve Stimulation for Neuropathic Pain

Over the last two decades, electrical neuromodulation has become a dominant approach in surgical treatment of medically refractory neuropathic pain, essentially eclipsing multiple available neuroablative procedures. Among different types of neuromodulation, peripheral nerve stimulation (PNS) holds the unique position of being the least invasive - and at the same time the least established in terms of scientific evidence and regulatory approvals. However, it is now gaining tremendous momentum in terms of accumulation of clinical experience and development of new indications. As a matter of fact, recent European approval of PNS for treatment of chronic lower back pain and intractable migraine headaches is expected to add legitimacy and marketing support to the entire field of PNS. This article provides an overview of PNS history, reviews current thoughts regarding its mechanism of action, summarises common indications, clinical outcomes, technical procedural details and complications, and suggests future directions for PNS development. It appears that PNS today is the most rapidly growing field of neuromodulation - and that does not come as a surprise, considering its potential for treatment of very prevalent and hard-to-treat conditions, such as back pain and headaches. From the point of view of a practising neurologist, PNS presents an attractive pain management option that combines a high level of efficacy and reproducibility of results with low invasiveness and minimal morbidity. As the worldwide experience with PNS continues to grow, one may expect to see it becoming a widely accepted treatment approach in a variety of clinical conditions.

Peripheral Nerve Stimulation for Neuropathic Pain

Over the last two decades, electrical neuromodulation has become a dominant approach in surgical treatment of medically refractory neuropathic pain, essentially eclipsing multiple available neuroablative procedures. Among different types of neuromodulation, peripheral nerve stimulation (PNS) holds the unique position of being the least invasive—and at the same time the least established in terms of scientific evidence and regulatory approvals. However, it is now gaining tremendous momentum in terms of accumulation of clinical experience and development of new indications. As a matter of fact, recent European approval of PNS for treatment of chronic low back pain and intractable migraine headaches is expected to add legitimacy and marketing support to the entire field of PNS. This article provides an overview of PNS history, reviews current thoughts regarding its mechanism of action, summarizes common indications, clinical outcomes, technical procedural details, and complications, and suggests future directions for PNS development. It appears that PNS today is the most rapidly growing field of neuromodulation—and that does not come as a surprise, considering its potential for treatment of very prevalent and hard-to-treat conditions, such as back pain and headaches. From the point of view of a practicing neurologist, PNS presents an attractive pain management option that combines a high level of efficacy and reproducibility of results with low invasiveness and minimal morbidity. As the worldwide experience with PNS continues to grow, one may expect to see it becoming a widely accepted treatment approach in a variety of clinical conditions.

Intractable migraine headaches during pregnancy under chiropractic care

The absence of hormone fluctuations and/or the analgesic effects of increased beta-endorphins are thought to confer improvements in headache symptoms during pregnancy. However, for a number of pregnant patients, they continue to suffer or have worsening headache symptoms. The use of pharmacotherapy for palliative care is a concern for both the mother and the developing fetus and alternative/complementary care options are sought. We present a 24-year-old gravid female with chronic migraine headaches since age 12years. Previous unsuccessful care included osteopathy, physical therapy, massage and medication. Non-steroidal anti-inflammatory medication with codeine provided minor and temporary relief. Chiropractic care involving spinal manipulative therapy (SMT) and adjunctive therapies resulted in symptom improvement and independence from medication. This document provides supporting evidence on the safety and possible effectiveness of chiropractic care for patients with headaches during pregnancy.

A Mass in the Temporomandibular Joint

A 55-year-old woman with a three-year history of progressive migraine headaches developed a rightsided posterior open bite and right preauricular facial swelling. Several primary and specialty medical and dental practitioners evaluated her case and made a diagnosis of intractable migraine headaches. Because of her progressive symptoms, she had been referred to the Division of Oral and Maxillofacial Surgery, Mayo Clinic (Rochester, Minn.), for further evaluation. The patient’s medical and surgical histories were unremarkable, including any history of facial trauma. Her facial pain and migraines had been treated with a range of overthe-counter and prescription analgesics, with limited success. At examination, the patient had a mild degree of right-sided preauricular facial swelling that was mildly painful to palpation and was associated with a malocclusion of approximately 3 millimeters on the right side and a posterior open bite with continued and progressive ipsilateral headaches. Panoramic plain radiography showed a spaceoccupying lesion in the right temporomandibular joint (TMJ) (Figure 1). A computed tomographic scan with intravenous contrast material disclosed a hypoattenuated mass occupying the right TMJ space, with cortical erosion and destruction of the glenoid fossa (Figure 2). The cortical architecture of the temporomandibular condyle was well-preserved, although it was displaced significantly and inferiorly, leading to the development of malocclusion. Cranial nerves were grossly intact, with no evidence of neurologic deficit in the trigeminal or facial nerve distributions. There was no evidence of involvement of the middle ear canal, and hearing was preserved. In the absence of a histologic diagnosis, the treating surgeon (D.K.) performed a right TMJ arthroplasty for open joint exposure and exploration. Upon entry into the TMJ space, the surgeon noted a large volume of cartilaginous foreign bodies in the intra-articular joint space. The articular surface of the mandibular condyle appeared to be wellpreserved; however, there was significant erosion and disruption of the glenoid fossa superiorly, with a small focus of intracranial extension. Despite a limited dural exposure, there was no significant cranial extension or cerebrospinal fluid leak. After removing the tumor, the surgeon repositioned the mandibular condyle within the glenoid fossa, resulting in improved occlusion. A mass in the temporomandibular joint

Propofol: A Novel Treatment for Breaking Migraine Headache

Valley Anesthesiology Consultants, Ltd, Phoenix, Arizona. jbloomstone@cox.netA small number of open-label trials1,2and case reports3,4support the use of intravenous propofol in subanesthetic doses for the management of chronic severe intractable migraine headache. The largest of these, which included 77 patients, reported an average reduction in headache intensity of 95.4%. In this study, 63 of 77 patients reported complete resolution of headache symptoms after receiving 120 mg of propofol delivered over 30 min.We report the case of a 54-yr-old woman who was admitted to the hospital with 2 weeks of severe, intractable migraine headache, complicated by severe hemicranial pain, photophobia, phonophobia, and a new left eyelid droop. After completing a full neurologic work-up, which was negative, the patient was diagnosed with status migrainous. Multiple medications, including gabapentin, pregabalin, sumatriptan, carisoprodol, promethazine, ketorolac tromethamine, and morphine sulfate, were all attempted with limited success.Our anesthesiology service was consulted by the patient’s neurologist for a subanesthetic trial of propofol, as reported by Krusz et al .1On the visual analog scale of 0-10, the patient reported a score of 6 for frontal head-pain and experienced significant photophobia just before the injection of propofol. She then received 20 mg IV every 5 min to a maximum of 120 mg over 30 min. Within 5 min, the patient’s pain scale score decreased to 5. By 20 min (80 mg), she reported a score of 2 and stated that she could not remember the last time she felt this good. By 30 min (120 mg), she reported a pain score of 0 and commented that she could remove her dark glasses without any photophobia and that her headache was gone. Five hours later, and after 5 days in the hospital, the patient was discharged home without pain.Although existing studies are small, this case report, in conjunction with smaller studies reported elsewhere, supports the use of propofol in subanesthetic doses for the treatment of severe migraine headache. These observations also suggest the involvement of the γ-aminobutyric acid type A receptor in the etiology of migraine headaches. It seems that a large-scale trial to examine the efficacy of propofol, at least for acute headache control, is warranted.Valley Anesthesiology Consultants, Ltd, Phoenix, Arizona. jbloomstone@cox.net