By Teri Robert and Dr. John Claude Krusz
Refractory Migraines – Migraines that are not responding to treatment – can present significant issues for Migraineurs, including status Migrainous. Unfortunately, even though there are effective treatments that can be tried, many doctors are not aware of them, or even if they’re aware of them, may not be set up to administer them. In such cases, these treatments may be administered outpatient at a hospital, sometimes through the emergency department. The information below was presented at the 49th Annual Scientific Meeting of the American Headache Society.
In the search for additional pharmacologic agents that can be given intravenously in the headache clinic, we chose to use IV lidocaine treatment for Migraineurs who were refractory (their Migraines were not responding to treatment) to usual treatment at home.
Lidocaine has been used to treat neuropathic pain by virtue of its ability to block sodium channels and thus block neuropathic pain signaling. On the theory that Migraines or other headaches may be, in part, neuropathically mediated, we treated refractory Migraines with this agent in the clinic.
- 22 patients were treated (19 female/3 male) [average age 40.8 yrs] for refractory Migraines in the clinic.
- An IV line was started with pulse oximetry monitoring. Patients had failed at home treatment for their usual Migraines. None were allergic to local anesthetics by history.
- An initial dose of 3mg/kg lidocaine (in normal saline) was infused over 90 minutes.
- Patients rated initial Migraine severity (on a 1-10 scale) and at timed 15 minute intervals.
- Following initial treatment, an additional 1.5-2 mg/kg lidocaine was infused over 1 hour if there were no side effects and if the Migraine reduction was less than 50%.
- The beginning severity for Migraines was 7.05/10 before treatment, and this was reduced to 2.18/10 in severity after treatment. 7 of 22 [32%] of patients had complete abolishment of their Migraines.
- 5 patients were in status migrainosus.
- Average time of lidocaine infusion was 135 minutes, and average dose was 334 mg of lidocaine.
- 10 patients were treated with a second dose of lidocaine. This resulted in a in significant decrease in headache severity for treatment of refractory Migraines.
- There were 4 patients with transient nausea and dizziness during infusion, easily arrested by stopping or slowing the infusion rate.
- No other side effects were seen with treatment.
We conclude that IV lidocaine can be used in the clinic for treatment of refractory Migraines and that sodium channel over-activity may be playing a role in the maintenance or perpetuation of Migraine attacks. Lidocaine is safe, very effective and very well tolerated, but must be monitored. Successful treatment may allow choice of a sodium channel active agent for oral prophylaxis of Migraines. The study also raises questions about mechanisms of aberrant neurotransmitter activity involving sodium channels playing a role in refractory Migraine.
Cammarata, Diane, APRN,BC; Cagle, Jane, LVN; Krusz, John Claude, PhD, MD. “IV Lidocaine - Effective Treatment for Refractory Migraines in the Clinic.” Research Poster Presentation. 49th Annual Scientific Meeting of the American Headache Society. Chicago. June, 2007.
Last Updated: July 30, 2007
Teri Robert is a leading patient educator and advocate and the author of Living Well with Migraine Disease and Headaches. A co-founder of the Alliance for Headache Disorders Advocacy and the American Headache and Migraine Association, she received the National Headache Foundation’s Patient Partners Award and a Distinguished Service Award from the American Headache Society. Teri can be found on her website, and blog, Facebook, Twitter, StumbleUpon, Pinterest, LinkedIn, and Google+.