Refractory Chronic Daily Headache Research Articles

Intermediate Cervical Plexus Block (ICPB) In Refractory Chronic Daily Headache After Whiplash: Prospective Audit In 43 Patients

Background: Chronic daily headache can develop or pre-existing episodic headache can worsen after whiplash and is termed persistent headache attributed to whiplash. It can be a therapeutic challenge and often results in severe disability. The objective was to assess the management of patients with refractory secondary chronic daily headache referred to a pain physician in consideration for greater occipital nerve block. Methods: Prospective service evaluation in adult patients with oro-facial pain and headaches. Patients underwent specialist neurology review and analgesic overuse headache was excluded. Patients with chronic daily headache with a past history of neck trauma were included. Cervical facet joint dysfunction and intracranial pathology were excluded. An initial cohort of 27 patients received occipital nerve block without benefit. Subsequently, all patients were offered ultrasound guided intermediate cervical plexus block with local anesthetic and steroid mixture. Four-week headache diary, Brief Pain Inventory-Short Form and Hospital Anxiety Depression Scale questionnaires were completed at baseline and three months post-intervention. Results: Over a 41-month period, 43 patients were reviewed. The first 27 patients (27/43, 63%) reported no benefit with occipital nerve block. Subsequently, patients were offered intermediate cervical plexus block(s). Four patients refused. Thirty-nine patients received the intervention. Thirty-two patients (32/39, 82%) reported significant reduction in headache frequency and intensity at three months. Failure rate was 18% (7/39). Conclusion: The cervical plexus could play a significant role in the development or worsening of pre-existing headache after whiplash. Intermediate cervical plexus block may have a role in the management of refractory chronic daily headache following whiplash injury.

Transnasal Sphenopalatine Ganglion Block for the Preventive Treatment of Chronic Daily Headache in Adolescents.

Chronic headaches are a major source of morbidity in the pediatric population, affecting physical function, school attendance, social capacity, mood, and sleep. In adults, repetitive sphenopalatine ganglion (SPG) blockade has been studied as a preventive treatment for chronic migraines. This case series aims to evaluate the SPG block for the preventive treatment of chronic daily headache (CDH) in adolescents. We prospectively evaluated 17 adolescents (14 females, 14 ± 1 year) with CDH not responding to cognitive behavioral therapy (CBT), physiotherapy, and standard medications. Each patient received 10 SPG blocks (two blocks/week) using the Tx360® device. At the end of treatment, 10 patients (59%) reported a Patient’s Global Impression of Change (PGIC) score ≥ 67%, and 3 months after the end of treatment, nine patients (53%) sustained a PGIC ≥ 67%. There was also a statistically significant reduction in the depression subscale of the Revised Children’s Anxiety and Depression Scale (RCADS) at the end of treatment and 3 months post-treatment compared with baseline. The procedure was well tolerated with no adverse effects. In our study, the use of repeat SPG blockade was associated with sustained benefits on the PGIC and the depression subscale of the RCADS when used as preventive headache treatment in adolescents with refractory CDH.

Update of Inpatient Treatment for Refractory Chronic Daily Headache.

Chronic daily headache (CDH) is a group of headache disorders, in which headaches occur daily or near-daily (>15days per month) and last for more than 3months. Important CDH subtypes include chronic migraine, chronic tension-type headache, hemicrania continua, and new daily persistent headache. Other headaches with shorter durations (<4h/day) are usually not included in CDH. Common comorbidities of CDH are medication overuse headache and various psychiatric disorders, such as depression and anxiety. Indications of inpatient treatment for CDH patients include poor responses to outpatient management, need for detoxification for overuse of specific medications (particularly opioids and barbiturates), and severe psychiatric comorbidities. Inpatient treatment usually involves stopping acute pain, preventing future attacks, and detoxifying medication overuse if present. Multidisciplinary integrated care that includes medical staff from different disciplines (e.g., psychiatry, clinical psychology, and physical therapy) has been recommended. The outcomes of inpatient treatment are satisfactory in terms of decreasing headache intensity or frequency, withdrawal from medication overuse, reducing disability, and improving life quality, although long-term relapse is not uncommon. In conclusion, inpatient treatment may be useful for select patients with refractory CDH and should be incorporated in a holistic headache care program.

EHMTI-0271. Refractory chronic daily headache and idiopathic intracranial hypertension: preliminary results of a prospective study

Results Among the 23 consecutive patients enrolled, 19 (13 F, 6 M; mean age 47.9 ± 12.3; mean BMI 26.1± 4.8) completed the study, 4 female patients dropped out. None of the 19 patients had papilledema. We found a TSS in 11 of 19 cases (58%): bilateral in 3 patients and unilateral in 8 cases. All of 19 cases displayed OP lower than 250 mmH2O (range 102-245) and normal CSF composition. We found a OP greater than 200 mmH2O only in four patients (1M, 3 F) (17%): two of them achieved an improvement of headache intensity and frequency after 12-18 ml CSF withdrawal; one of them had bilateral TSS.

Experience With Botulinum Toxin Type A in Medically Intractable Pediatric Chronic Daily Headache

In adults, botulinum toxin type A has been studied as a potentially effective treatment for chronic daily headache. For pediatric chronic daily headache, the literature evaluating efficacy of botulinum toxin type A is sparse, with no studies assessing tolerability. The purpose of this retrospective case series study was to assess tolerability and efficacy of botulinum toxin type A in the treatment of pediatric chronic daily headache. The series comprises 10 patients (ages 11-17 years) who received a standard 100-unit dose of onabotulinumtoxinA (trade name, Botox) for refractory chronic daily headache. Attention was given to therapeutic history, efficacy, and tolerability. The patients had attempted an average of 8.0 ± 2.40 S.D. therapies prior to botulinum toxin type A. Most patients reported adverse events from at least one of these prior medications. With botulinum toxin type A, four patients (40%) reported subjective but clinically meaningful relief, consisting of a decrease in headache intensity, and two patients additionally noted a decrease in headache frequency. The four responders noted improvements in quality of life. Three patients experienced minor adverse events from botulinum toxin type A. This case series suggests that botulinum toxin type A can be well tolerated and may be a useful therapeutic in pediatric patients with highly medically intractable chronic daily headache.

Vagus nerve stimulation in drug-resistant daily chronic migraine with depression: preliminary data

Drug refractory chronic daily headache (CDH) is a highly disabling condition. CDH is usually regarded as the negative evolution of chronic migraine (CM) and is characterized by high prevalence of psychiatric disorders, especially mood disorders. Vagal nerve stimulation (VNS) is an established treatment option for selected patients with medically refractory epilepsy and depression. Neurobiological similarities suggest that VNS could be useful in the treatment of drug-refractory CM associated with depression. The aim of the study was to evaluate the efficacy of VNS in patients suffering from drug-refractory CM and depressive disorder. We selected four female patients, mean age 53 (range 43-65 years), suffering from daily headache and drug-refractory CM. Neurological examination and neuroradiological investigations were unremarkable. Exclusion criteria were psychosis, heart and lung diseases. The preliminary results in our small case series support a beneficial effect of chronic VNS on both drug-refractory CM and depression, and suggest this novel treatment as a valid alternative for this otherwise intractable and highly disabling condition.

Intravenous Lidocaine in the Treatment of Refractory Headache: A Retrospective Case Series

New treatments are needed to treat chronic daily headache (CDH) and chronic cluster headache (CCH). New treatments are needed to treat this population and intravenous (IV) lidocaine is a novel treatment for CDH. The aim of this study was to examine the use of IV lidocaine for refractory CDH patients in an inpatient setting. This was an open-label, retrospective, uncontrolled study of IV lidocaine for 68 intractable headache patients in an inpatient setting. We reviewed the medical records of patients receiving IV lidocaine between February 6, 2003 and June 29, 2005. Pretreatment headache scores averaged 7.9 on an 11-point scale and posttreatment scores averaged 3.9 representing an average change of 4. Average length of treatment was 8.5 days. Lidocaine infusion was generally well tolerated with a low incidence of adverse events leading to discontinuation of treatment. This study suggests benefit of lidocaine treatment and the need for further prospective analyses. The mechanism of lidocaine in treating headache is unknown.

Continuous Opioid Therapy (COT) is Rarely Advisable for Refractory Chronic Daily Headache: Limited Efficacy, Risks, and Proposed Guidelines

Intractable pain, headache or otherwise, is a devastating and life-controlling experience. The need to effectively and aggressively control pain is a fundamental tenet of clinical care. In the past several years, increasing advocacy for continuous opioid therapy has become an important, if not controversial, theme in the development of treatment guidelines and teaching programs. Ironically, the increasing willingness of physicians to prescribe scheduled opioids for their headache and pain patients has occurred in the absence of compelling data demonstrating efficacy or long-term safety. To the contrary, two meta-analyses on chronic noncancer pain (CNCP) and one long-term uncontrolled study on headache patients demonstrate a relatively small number of patients benefiting from the treatment. Recent neuroscience data on the effects of opioids on the brain raise serious concern for long-term safety and also provide the basis for the mechanism by which chronic opioid use might induce progression of headache frequency and severity. Significant adverse effects, including influence on sexual hormonal balances, physical and psychological dependence, the development of opioid-induced hyperalgesia, and cardiac arrhythmia and sudden death that can be seen with standard dosages of methadone, make a strong argument against widespread use of continuous opioid therapy (COT) in otherwise healthy young and middle-aged headache patients. We believe that COT should be used in rare circumstances for chronic headache patients, and propose initial guidelines for selecting patients and monitoring treatment. The physician should be well versed in the details of opioid prescribing, administration, and monitoring, and should be prepared to discontinue opioids when clinical justification, patient behavior, or failure to achieve therapeutic goals make discontinuance necessary.

Ziprasidone provided "significant and sustained headache improvement" in three migraineurs with refractory chronic daily headache,

Ziprasidone provided "significant and sustained headache improvement" in three migraineurs with refractory chronic daily headache,

Treatment of Refractory Chronic Daily Headache with the Atypical Antipsychotic Ziprasidone — A Case Series

Treatment of Refractory Chronic Daily Headache with the Atypical Antipsychotic Ziprasidone — A Case Series

Topiramate in the treatment of refractory chronic daily headache. An open trial

Chronic daily headache (CDH) is a debilitating disorder that becomes a treatment challenge in patients refractory to the treatment. We hereby report our experience with topiramate treatment in patients with refractory CDH. The study design was a prospective, protocol–based follow–up and retrospective analysis of headache diaries. We treated with topiramate at slowly increased moderate increments 11 CDH patients who were refractory to multiple previous treatments. Topiramate treatment was effective in 7 (64%) patients. The treatment resulted in a 66% (median) decrease of the headache days per week and a significant decrease in headache severity, a reduction of the headache hours per day, and weekly analgesic consumption. These effects continued for an average follow–up of 8±4 months. The average effective dose was 100 mg/day. Slowly increasing the drug at moderate increments resulted in high tolerability of topiramate. We found topiramate to be an effective long–standing treatment option for patients with refractory CDH. Slow increments of the dosage contributed to high tolerability of the drug.

Headache profile in patients with idiopathic hypertrophic cranial pachymeningitis.

Idiopathic hypertrophic cranial pachymeningitis (IHCP) is an uncommon disorder due to localized or diffuse thickening of the dura mater. While headache is the most common manifestation, the clinical characteristics of the headache in IHCP have not been well characterized. From 1996 to 2002, 6 consecutive patients with IHCP presenting with headache were reviewed (3 women, 3 men; mean age: 49 years). Diagnosis was based on characteristic neuroimaging findings and the exclusion of secondary causes of cranial pachymeningitis. This study reported the headache characteristics, neuroimaging features, and longitudinal follow-up. Chronic daily headache, especially chronic migraine, was the most common headache pattern observed (4/6 patients). Lateralization of headache location appeared to correlate with the distribution of the hypertrophied dural lesions. Diagnostic delay was due to failure to evaluate with gadolinium-enhanced MRI. After treatment, headache (5/6, 83%) and neurologic deficits (2/3, 67%) improved in most patients; however, follow-up MRIs (n = 5) showed deterioration in 3 patients. The headache of IHCP is typically a chronic daily headache, often resembling chronic migraine. Correspondingly, IHCP should be considered in the differential diagnosis of refractory chronic daily headache, with or without associated cranial neuropathy or other associated neurologic deficits. The typical imaging finding on gadolinium-enhanced MRI is localized or diffuse pachymeningitis and failure to order a gadolinium-enhanced MRI is the primary reason for delayed diagnosis. Despite symptomatic improvement on longitudinal follow-up, the MRI abnormalities may not improve in parallel with the clinical symptoms.

Zonisamide improves total headache time and headache index in refractory chronic daily headache

Abstract Basic research and clinical results indicate that zonisamide may have efficacy as a preventive medication for headache disorders. This article reports clinical experience with zonisamide [Zonegran®] in the treatment of chronic daily headache. Evaluations of headache frequency, duration, severity, and disability were done for 18 patients with refractory chronic daily headache before and 3 months following the establishment of a stable dosage of zonisamide. Total monthly headache time and headache index (frequency × duration × severity) were calculated. Preventive therapy with zonisamide was associated with improvements in frequency, duration, severity, and disability. Average headache index score improved by 65% and average total monthly headache time decreased by 55%. Zonisamide was well tolerated with minimal adverse events.

Frequent triptan use: observations on safety issues.

To examine the safety of frequent triptan use over extended periods. For a small group of patients with refractory migraine plus chronic daily headache, triptans are effective. This retrospective study primarily evaluated the cardiac safety of daily triptan use in 118 patients and, in addition, hematologic tests were assessed. Each patient had utilized a triptan for a minimum of 4 days per week for at least 6 months. Patients with rebound headache had been withdrawn from the triptans. Most patients (97 of 118) averaged 1 tablet daily; most would occasionally go for several days without a triptan. Forty patients had taken a triptan for 6 months to 2 years, 37 patients from 2 to 4 years, and 41 for 4 or more years. Routine hematologic tests were performed periodically on all patients, and no abnormalities were attributable to triptans. Almost all patients had an electrocardiogram, and no abnormal electrocardiograms were felt to be related to triptans. Cardiac echocardiography was performed in 57 patients. The 10 abnormal echocardiograms were not due to triptans. All 20 cardiac stress tests revealed normal findings. Adverse events were minimal; 9 patients described fatigue due to triptans, and 5 had mild chest tightness. This long-term study of 118 patients indicates that frequent triptan use may be relatively safe.

Intravenous propofol in the treatment of refractory headache.

We analyzed the results of treating patients who had chronic daily headaches that were refractory to standard medications with repetitive low-dose boluses of intravenous propofol (2,6-diisopropylphenol). Patients were treated over a 1-year period at Thomas Jefferson University Hospital. A total of 18 patients were treated a total of 21 times. Over 90% of patients had at least some headache relief after treatment. The headache cycle was broken in eight patients. There were no complications. Intravenous propofol is safe and effective when used under monitored conditions and should be considered for patients who have refractory chronic daily headache and have failed other interventions.

Olanzapine in the treatment of refractory migraine and chronic daily headache.

Olanzapine, a thienobenzodiazepine, is a new "atypical" antipsychotic drug. Olanzapine's pharmacologic properties suggest it would be effective for headaches, and its propensity for inducing acute extrapyramidal reactions or tardive dyskinesia is relatively low. We thus decided to assess the value of olanzapine in the treatment of chronic refractory headache. We reviewed the records of 50 patients with refractory headache who were treated with olanzapine for at least 3 months. All previously had failed treatment with at least four preventative medications. The daily dose of olanzapine varied from 2.5 to 35 mg; most patients (n = 19) received 5 mg or 10 mg (n = 17) a day. Treatment resulted in a statistically significant decrease in headache days relative to baseline, from 27.5 +/- 4.9 before treatment to 21.1+/-10.7 after treatment (P <.001, Student t test). The difference in headache severity (0 to 10 scale) before treatment (8.7+/-1.6) and after treatment (2.2 +/- 2.1) was also statistically significant (P <.001). Olanzapine may be effective for patients with refractory headache, including those who have failed a number of other prophylactic agents. Olanzapine should receive particular consideration for patients with refractory headache who have mania, bipolar disorder, or psychotic depression or whose headaches previously responded to other neuroleptic medications.

Repetitive intravenous prochlorperazine treatment of patients with refractory chronic daily headache.

To investigate the efficacy and long-term outcome of intravenous prochlorperazine for the treatment of refractory chronic daily headache. Unlike dihydroergotamine, the treatment results of intravenous neuroleptics as first-line agents for refractory chronic daily headache have rarely been reported. We retrospectively analyzed the data of inpatients with refractory chronic daily headache who received intravenous repetitive prochlorperazine treatment from November 1996 to March 1999. A semistructured telephone follow-up interview was done in September 1999. A total of 135 patients (44 men, 91 women) were recruited, including 95 (70%) with analgesic overuse. After intravenous prochlorperazine treatment, 121 (90%) achieved a 50% or greater reduction of headache intensity, including 85 (63%) who became headache-free. The mean hospital stay was 6.2 +/- 2.7 days, and mean total prochlorperazine used was 98 +/- 48 mg. Acute extrapyramidal symptoms occurred in 21 patients (16%). One hundred twenty-four patients (92%) were successfully followed up, with a mean duration of 14.3 +/- 7.5 months. Compared with pretreatment status, 93 patients (75%) considered their headache intensity decreased, and 86 patients (69%) considered their headache frequency decreased, although 40 (32%) still had a daily headache. Of the 87 patients with analgesic overuse who could be followed, 61 (70%) no longer overused analgesics. Poor response to prochlorperazine treatment (relative risk, 1.8) and presence of major depression (relative risk, 1.8) were predictors of persistent chronic daily headache at follow-up. Prochlorperazine was effective and safe in the treatment of patients with refractory chronic daily headache with or without analgesic overuse. Compared with dihydroergotamine, prochlorperazine seemed less effective at achieving "freedom from headache" during hospitalization, but had a similar outcome at follow-up.

Coexistence of migraine and idiopathic intracranial hypertension without papilledema

Eighty-five patients with refractory transformed migraine type of chronic daily headache (CDH) had spinal tap as a part of diagnostic work-up. Twelve had increased intracranial pressure without papilledema, transient visual obscurations, or visual field defects. The headache profile of these 12 patients was not different from that of transformed migraine type of CDH. Acute headache exacerbations responded to specific antimigraine agents such as ergotamine, dihydroergotamine (DHE), and sumatriptan, whereas prophylactic antimigraine medications were only partially helpful. Addition of agents such as acetazolamide and furosemide, after the diagnosis of increased intracranial pressure, resulted in better control of symptoms. These observations suggest a link between migraine and idiopathic intracranial hypertension that needs further research. In refractory CDH with migrainous features, a spinal tap to exclude coexistent idiopathic intracranial hypertension without papilledema may be indicated.

Phenelzine therapy for headache patients with concomitant depression and anxiety.

Eleven patients with refractory chronic daily headache, associated depression, and generalized anxiety were treated with phenelzine. Ten patients (91%) had a greater than or equal to 50% improvement in headache frequency, seven (64%) had a similar degree of improvement in mood and headache intensity or activity level. Orthostatic hypotension was the most common side effect and necessitated discontinuation of therapy in two patients. One patient suffered a hypertensive crisis which was easily managed and caused no permanent sequelae. Based on these preliminary results, we conclude that phenelzine is effective in the treatment of chronic daily headache with associated depression and anxiety, but further investigations are needed to determine if there is selective efficacy of phenelzine for this subgroup of patients.