Sometimes, despite the best treatment, migraine will not respond. When several common treatments fail, doctors refer to it as refractory migraine. While not a true diagnosis, the term is recognized and used by migraine specialists. At headache centers, these refractory migraines can be treated with IV infusions of a variety of medications.
Ketamine infusions have been used to successfully treat complex regional pain syndrome, fibromyalgia, depression and even chronic pain patients with opioid tolerance. Ketamine is thought to reduce the body’s response to repetitive painful stimuli, possibly reversing the process of central sensitization. So a team of specially trained doctors and nurses at Thomas Jefferson University Hospital in Philadelphia began treating a select group of patients with IV ketamine infusions. In February, 2017, the result of these treatments was published in Headache documenting the results.
A total of 82 patients were admitted inpatient for ketamine infusion from January, 2006 to December, 2014. Seventy-seven patients were diagnosed with chronic migraine or new daily persistent headache. The remaining five patients had cluster headache or visual snow. Results of their treatment was not included in this analysis.
Patient treatment details
- Dose began at 0.1 mg/kg/hr
- Increased by 0.05 mg/kg/hr until pain relief was achieved
- Target dose was maintained for six hours
- Patient was then assessed for a possible dose increase.
- Maximum dose of 1 mg/kg/hr
- Duration of treatment was two to nine days (avg. five days)
- Frequent monitoring of vital signs, sedation, and adverse events
- Administered medication to counteract side effects
- Additional inpatient treatments:
- 12 received DHE.
- 40 received neuroleptics.
- 28 received NSAIDs.
- Average pain at admission was 7.1 using a scale of zero to 10.
- Average pain at discharge was 3.8, using a scale of zero to 10.
- Fifty-five patients (71.4%) dropped at least two points.
- Fifteen (27.3%) maintained improvement at a one-month follow-up.
The positive results of this study may not apply to all headache disorder patients. Participants in this study had failed multiple treatment trials, including prior inpatient infusion therapy using other medications. Even when ketamine was used, other treatments were also provided that were unique to each patient. The subjects are described as, “frankly desperate, population of patients who already failed to respond adequately to inpatient treatment not involving ketamine, and what may have been required for some patients to improve is this unique combination of treatments including those that had not worked well in relative isolation in the past.”
Ketamine may be a promising treatment for patients with severe, refractory headaches. It is considered an acute treatment as patients continue with preventive treatments between infusions. One challenge for future studies is that the treatment effects of ketamine are unique and difficult to mask. That makes it difficult to conduct a true double-blind, placebo-controlled study.The researchers recommend future efforts to study ketamine infusion for refractory migraine should
- use controlled dosing.
- design long-term, prospective studies.
- enroll subjects with less severe headache symptoms.
- select patients carefully due to potential side effects.
- closely monitor all patients for falls, mood changes, adverse
- events, heart rate, blood pressure, and liver enzymes.
Beyond the study results
Study results give us valuable information about the relative effectiveness of a treatment. They are objective and measurable, but they don’t tell the patients’ stories.Remember the five patients whose results were not included because of their diagnoses? One of those patients, Chris Hannah, had this to say about his experience,
"I have been undergoing ketamine infusion therapy for chronic intractable cluster headache for the past 3 years. Each infusion session is 5 days and nights in hospital. The relief I feel from the infusions has been tremendous. I have a pain free period following the infusion usually for 8-10 weeks before cluster attacks start to slowly return along with baseline headache pain."3
None of the patients experienced complete pain relief. That sounds disappointing. However, for at least one of the patients involved, even a reduction in pain severity is sweet relief. Katie Golden tell us,
"I typically enter the hospital with an average pain level of between 6 - 8. After the five day infusion, it doesn’t cure my migraine attacks, but it reduces my average pain level down to 3 or 4. This is life changing. I am more productive and have more energy. I still need to take my preventative medications, make sure I sleep enough (including a daily nap) and continue to focus on my general well-being. The effects last 4 - 6 months and I now have a routine of getting in-patient ketamine infusions twice a year."3
Despite the positive results, Katie also urges caution. Ketamine is a powerful hallucinogenic with serious side effect. Katie shares this wisdom with anyone considering ketamine,
"I am a big believer in the powerful effects that ketamine has on chronic migraine. But I want people to understand that it is a serious drug, not for the faint of heart. If you’re thinking about exploring this option, it should only be after you have exhausted other traditional treatments. The positive benefits of ketamine infusions can come with serious side effects that you need to be prepared for. It’s a hallucinogenic drug. You may become paranoid, have vivid dreams, experience double vision or need help walking."3
1 Pomeroy JL, Marmura MJ, Nahas SJ, Viscusi ER. Ketamine infusions for treatment refractory headache. Headache: The Journal of Head and Face Pain. 2016;57(2):276–282. doi:10.1111/head.13013.
2 Interview with Chris Hannah on February 28, 2017.
3 Interview with Katie Golden on February 28, 2017.
More helpful information:
Reviewed by David Watson, MD.
© Tammy Rome, 2017.
Headache disorders advocate, blogger, and mental health therapist, Tammy maintains a private practice specializing in behavioral pain management, as well as writing for her own blog, Brain Storm. She also volunteers as Vice Chair of the American Headache and Migraine Association and as President of The Cluster Headache Support Group. You can read more of Tammy’s work on her blog and follow her on Facebook, Twitter, StumbleUpon, Pinterest, LinkedIn, and Google+.
Headache disorders counselor and advocate Tammy Rome maintains a private practice specializing in treating clients with Migraine and other headache disorders. She also volunteers as vice chair of the American Headache and Migraine Association and as president of The Cluster Headache Support Group. You can read more of Tammy’s work on her website and follow her on Facebook, Twitter, StumbleUpon, Pinterest, LinkedIn, and Google+.