089 Breaking the cycle of chronic daily headache with a low-dose subcutaneous lignocaine and ketamine infusion

IntroductionManagement of chronic migraine includes correcting analgesic rebound headache and implementing suitable medication for prevention and acute episodes. However, in many cases this management paradigm oversimplifies the complexity of chronic migraine, particularly the entrenched central pathways that perpetuate chronic migraine. Intravenous lignocaine can curtail chronic migraine and analgesic rebound headache (1). Further, ketamine provides short-term analgesia and enables reduction in central sensitisation of pain pathways, particularly in the setting of codeine/opiod overuse (2). This paper describes use of subcutaneous lignocaine and ketamine infusion in chronic migraine.MethodsA prospective observational cohort study was undertaken in patients with chronic migraine. Patients received a prolonged subcutaneous lignocaine and ketamine infusion (mean duration 11 days) and underwent evaluation at four-time points over six months. The effects on the excitability of motor axons in the median nerve were documented using standard procedures.ResultsFourteen patients were recruited. The infusion was well tolerated; no major side effects were seen. There were no significant long-term changes in the excitability of motor axons. At six months, 13/14 patients had sustained benefit. Three of 4 patients remained free of analgesic rebound headache. One patient remained headache-free. Conversion to episodic migraine occurred in 6/14. Improvement in chronic migraine was reported by 6/14. Three of six were able to return to work, with 1 returning to studies. Benefit was greater in those with depression and history of opiod/codeine use.ConclusionSubcutaneous lignocaine and ketamine can help break entrenchment in chronic migraine as part of a structured management plan.

Oxygen delivered by a high flow concentrator for the treatment of medication-overuse headache

Treatment of medication-overuse headache (MOH) relies on detoxification, during which patients face rebound headache without alternative to painkiller. As oxygen has been proven effective for cluster and other headache subtypes, we sought to evaluate use of normobaric oxygen delivered by a high flow concentrator (HFC) in patients suffering MOH. For this purpose, twenty patients with MOH were included in this prospective monocentric open-labeled feasibility study. All patients received standard care with detoxification in addition to HFC delivering normobaric oxygen at 9 l/min, used to their discretion to treat rebound headache. Primary endpoint was acceptance of HFC and secondary endpoints evaluated its efficacy. Four patients were lost of follow-up after inclusion, one was excluded. HFC was accepted by 14/15 (93.3%). At M6 of follow-up, 15/15 (100%) reverted to episodic headache. In conclusion, normobaric oxygen delivered by HFC appears to be safe, feasible, and probably efficient to help patient with MOH who undergo withdrawal therapy. A larger double-blind, sham-controlled prospective study is needed. Trial registration: Clinical trials: NCT02302027.

Fájdalomcsillapító-túlhasználathoz társuló fejfájás

Medication-overuse headache affects 1 to 2 percent of the population. Any kind of painkiller, if taken regularly at least 10 days per month can cause medication-overuse headache, and therefore the possibility of this headache has to be raised whenever a patient with a preexistent headache notices a significant increase in headache frequency during a period of frequent painkiller consumption. Medication-overuse headache is most prevalent in females between 40 and 50 years of age. Its main risk factors are smokig, obesity, depression, and anxiety. The pathomechanism of medication-overuse headache is complex, with a probable genetic propensity and other biological (neurochemical and neurophysiological), as well as psychological and behavioural factors (such as anticipatory anxiety, catastrophisation of pain and consequentially a compulsive painkiller use) contributing to its genesis. The prerequisite of successful treatment is the withdrawal of the overused substance, other necessary elements of the therapy include the treatment of withdrawal symptoms including rebound headache, the introduction of an effective preventative therapy, taking into consideration the highly prevalent comorbid disorders as well, and the education and psychological support of patients. As the relapse rate can be as high as 30 to 40% regardless of effective treatment, the prevention of medication-overuse headache is of paramount importance, and the role of general practitioners can hardly be overstated. Orv. Hetil., 2015, 156(30), 1195–1202.

Hospital management of intractable headaches. The Instituto de Neurologia de Curitiba approach

Intractable headaches, also called refractory headaches, are usually unresponsive to standard therapies and comprise clinical conditions that represent a clinical management problem regarding therapy. Thereby, many approaches to manage "intractable headaches" have been proposed; meanwhile many aspects remain unclear and open to debate. Accordingly, these patients often require special care and customized management, such as inpatient treatment. Hospitalization aims to enhance management of the patients as a whole and thus improve their quality of life. This paper summarizes the Instituto de Neurologia de Curitiba (INC) approach, which comprises withdrawal of the overused medication, management of abstinence symptoms, management of rebound headache, introduction of effective prophylactic therapy, general counseling and education of the patient, and other aspects of management. The inpatient approach used at the INC is presented and a small sample of patients treated according to this approach is described and discussed.