I know of no published studies looking at this medication in this setting. Sometimes, interesting results are stumbled upon serendipitously, as occurred in the case of the pre-anesthetic agent propofol. A cognitive disorder is when your brain does not work correctly after a traumatic brain injury (TBI). American Pain Society's 27th Annual Scientific Meeting. Lamotrigine for chronic neuropathic pain. Cost effectiveness of clinic treatment of headaches and pain. Although methocarbamol is an older muscle relaxant preparation with uncertain pharmacologic mechanism(s) of action, it is one of the very few available in an IV form and, for this reason, I sometimes use it in the clinic to treat migraines and other headaches—especially if accompanied by a lot of neck spasms. Olesen J, Goadsby PJ, Ramadan NM, Tfelt-Hansen P, Welch KMA. Can a Buprenorphine Transdermal System (Butrans) Be Used to Treat OUD? Aura in some patients with familial hemiplegic migraine can be stopped by intranasal ketamine. The first two medications were originally approved as anticonvulsants, but were found to be effective in managing migraine, chronic daily headaches, and cluster headaches. Alcohol and drug use. Emergency Treatment for TBI Emergency care may include: 1. Stewarts Soundbites Episode 13 : Distinguishing treatable symptoms after Traumatic Brain Injury. It has been estimated that the direct medical costs and indirect costs, such as lost productivity, of TBI totaled an estimated $76.5 billion in the United States in 2000.17,18. Traumatic brain injury (TBI) is commonly defined as an insult to the brain from an external force that causes temporary or permanent impairment in functional, psychosocial, or physical abilities.1 It is a significant cause of morbidity and mortality, and the leading cause … The results showed an average reduction in pain severity after treatment from 7.46 on the visual analogue scale (VAS) to 2.81 (P<.001).76. 56Krusz JC. More than 95% of our clinic patients fared exceedingly well as far as their headache and pain symptoms were concerned.16 We arbitrarily defined success as a greater than 50% reduction in the headache, based on a 0 out of 10 visual analog scale (VAS) from baseline. Objective: To investigate clinical characteristics and treatment patterns in persistent post-traumatic headache attributed to mild traumatic brain injury. What are the risks of rehab after traumatic brain injury? Repairing skull fractures 3. Intravenous magnesium sulfate relieves cluster headaches in patients with low serum ionized magnesium levels. Dr Silver provides a general inpatient and outpatient neurology service for a full range of neurological disorders (including epilepsy, blackouts, MS, neuropathy, sleep disorders, dementia, stroke, etc). A traumatic brain injury can lead to many changes in a person’s life. Nausea should always be treated alongside the migraine. Memantine: novel mechanism for migraine and headache prophylaxis. The study found that IV metoclopramide 20 mg was more effective than sumatriptan 6 mg subcutaneously at reducing pain intensity scores (reduction of 7.2 vs 6.2, respectively) and pain-free rates (59% vs 35%, respectively).26. Subscribe – In order to receive our news straight to your inbox, subscribe here. The author has used venlafaxine (Effexor), duloxetine (Cymbalta), and milnacipran (Savella) off-label in his clinical practice. Theses agents primarily decrease neural activity in trigeminovascular afferent nerves that are sending signals from dural nerve endings to the trigeminal nucleus caudalis in the brainstem. A cohort of 77 patients were treated and the results were dramatic.55 Propofol was the most effective IV agent that we had ever employed, with a 95% success rate in reducing ongoing migraine headaches. May 2013: Abstract 381. As swelling decreases and blood flow and brain chemistry improve, brain function usually improves. Krusz JC. New Orleans, Louisiana. In the future, we will undoubtedly have more unique pharmacologic agents to treat post-TBI migraines more effectively. Chicago, Illinois. They are indicated for moderate to severe migraines, but early intervention in the migraine process is always desirable. In addition, Botox is currently the only medication approved for prophylactic treatment of chronic migraine (Table 2). Time: 1:00 -­ 1:15pm. An IV form is available in Europe. Rozen TD. Comparison of dihydroergotamine with metoclopramide versus meperidine with promethazine in the treatment of acute migraine. Toronto, Canada. Our study included 85 intractable migraineurs. We developed an IV form of the same agent (with a compounding pharmacy) and evaluated levetiracetam IV in the treatment of refractory migraines. P7C3-A20 treatment one year after TBI in mice repairs the blood–brain barrier, arrests chronic neurodegeneration, and restores cognition. If you require assistance from our team, please contact us or alternatively request a call back from one of our lawyers by submitting this form. A comparative trial of three agents in the treatment of acute migraine headache. Headache is the most common and among the most prevalent persistent symptoms following mTBI. Stillman MJ, Zajac D, Rybicki LA. They also have vasoconstrictive properties on blood vessels in this system, but the main effect is on neural firing. Potentiation of opioid analgesia in dopamine. The manufacturer subsequently released an IV preparation for commercial use to treat only seizures, but our data preceded that formulation by several years. Nicolodi M, Sicuteri F. Exploration of NMDA receptors in migraine: therapeutic and theoretic implications. Dr Silver is a pre-eminent Consultant Neurologist at The Walton Centre. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm350866.htm. Brussels, Belgium. Elvis Presley: Head Trauma, Autoimmunity, Pain, and Early Death, Traumatic Brain Injury: Treatment of Post-traumatic Headaches, Advances in Pharmacologic Pain Management of Juvenile Idiopathic Arthritis, Integrative Treatment Approaches for Juvenile Idiopathic Arthritis, How Changing Hydrocodone Scheduling Will Affect Pain Management, Editor's Memo: Interpreting Indications For Electromagnetic Therapy. Migraine headache: immunosuppressant therapy. Krusz JC, Cammarata D, Cagle S. IV ketamine for treatment of refractory pain disorders in the clinic. The Brain Injury Network (BIN), a brain injury survivor advocacy organization, recommends the emphasis of a traumatic brain injury (TBI) classification entitled Post TBI Syndrome. Traumatic brain injury (TBI) is a leading cause of cognitive impairment that affects millions of people worldwide. In the first few weeks after a moderate to severe brain injury, swelling, bleeding or changes in brain chemistry often affect the function of healthy brain tissue. Scherl ER, Wilson JF. Most often these have the characteristics of migraines, migrainous headaches, and mixed tension-type headaches (TTH) and migraines, as was discussed in Part 1 of this series.1 There have been a number of recent articles in medical journals that have renewed the debate about TBI, including an article by Robbins and Conidi on sports-related injuries. Before triptans, the gold standard for treating intractable migraines was DHE, a compound similar to, but pharmacologically very different from, ergotamine. This part of the article attempts to describe more aggressive and definitive treatments available in the outpatient headache clinic setting. Always wear a seat belt in a motor vehicle. Williams DR, Stark RJ. Krusz JC, Cagle J, Daniel D. Intravenous levetiracetam for acute intractable migraines. Raskin NH. I have had about 200 patients over the last 15 years for whom the addition of methocarbamol (range: 300-500 mg) was a positive element in their overall headache relief. Deep brain stimulation (DBS) is the most effective surgical treatment for tremors. Nicolodi M, Sicuteri F. Negative modulators of excitatory amino acids in episodic and chronic migraine: preventing and reverting chronic migraine. The agent is usually well tolerated in the lower doses used for headaches; however, the FDA recently issued a warning that valproate sodium can cause decreased IQ scores in children whose mothers took the medication during pregnancy. This condition is … Opioid Prescribing and Monitoring - Second Edition, Opioid Prescribing and Monitoring - First Edition. Role of magnesium in the pathogenesis and treatment of migraines. Prophylaxis for chronic daily headache and chronic migraine with neuronal stabilizing agents. When: Wednesday 2 December In the past, promethazine was the most frequently used antiemetic.25 However, our preference is to use either ondansetron or metoclopramide, both IV and intramuscular (IM), as a firstline antiemetic in the clinic. Philadelphia, Pennsylvania: June 2005. The specific pharmacologic effect of propofol, with sole effects on subtypes of the gamma-aminobutyric acid type A (GABA-A) receptor, is a unique mechanism of action. Additional surgery may include: 1. We reported an 88% reduction in severity of migraine, based on patient-rated VAS, in the IV valproate sodium group. Quite frankly, the "classic" migraine-specific abortive medications used for treatment of acute migraines and migrainous headaches—for example, dihydroergotamine (DHE-45) and triptans—are FDA indicated for moderate to severe migraines. Krusz JC. He is also involved in treatment trials for idiopathic intracranial hypertension. Vinson DR. 32nd Annual Scientific Meeting of the American Pain Society. Our preference is for the prescription of the more potent antiemetics, including ondansetron or metoclopramide. Atlanta, Georgia. Edwards KR, Norton J, Behnke M. Comparison of intravenous valproate versus intramuscular dihydroergotamine and metoclopramide for acute treatment of migraine headache. Multiple types of headaches, including migraines, migrainous headaches, TTH, and cluster headaches responded to IV magnesium therapy.19 The headache sufferers with the best and longest response to this treatment also had the lowest ionized Mg++ levels, both for migraines as well as for cluster headaches.20 One study has summarized clinical data with IV MgSO4 using doses of 0.5 to 1 g.23 In general, the author uses higher doses than that, and typically uses 2.5 to 3 g.21,22, Antiemetics have been used along with acute opioid therapy for headaches and for pain treatment. A number of strategies can help a person with traumatic brain injury cope with complications that affect everyday activities, communication and interpersonal relationships. Rehab after a TBI is not likely to cause problems. A severe head injury can also cause other potentially serious complications, including: an infection after … The average dose was 423 mg (range: 250-1,100 mg), given over 95 minutes in our clinic. April 2009: Abstract 221. Reutens DC, Fatovich DM, Stewart-Wynne EG, Prentice DA. We will only contact you in connection with your enquiry and won’t pass your details to any third parties. May 2013. Saadah HA. Letters to the Editor: Testosterone, Ultra-high Dose Opioids. The total dose (subanesthetic) was only 120 mg, given slowly by IV push 20 mg at a time. One of the initial studies using IV droperidol used quite high doses (mean 16.6 mg) and reported nearly all of their patients being sedated and more than 50% having extrapyramidal symptoms 24 hours after treatment.31 We repeated the study in our clinic using from one fifth to one quarter of the dose of IV droperidol with only 3% side effects and well over 50% success rate in reducing or eliminating refractory migraines.32 A double-blind trial of IM droperidol,33 again using high doses of the medication, showed efficacy; the placebo response rate was 57% vs 84% for droperidol. Tampa, Florida. Hering Rand Kuritsky A. A small child should always sit in the back seat of a car secured in a child safety seat or booster seat that is appropriate for his or her size and weight. Sedation and cognitive side effects, such as confusion or memory problems, however, may limit the use of topiramate. Therefore, approach to neurological rehabilitation and physiotherapy post-traumatic brain injury should observe neuroplasticity, motor learning, and motor control principles as well as the patient-centred approach with an individual’s goals settingand choice of treatment procedures. Source: Our health information content is based on research evidence whenever available and represents the consensus of expert opinion of the TBI Model System directors. Hand PJ, Stark RJ. Anticonvulsants 4. Tanen DA, MillerS, French T, Riffenburgh RH. It’s not surprising that headache would be the most common physical symptom after a brain injury. He explains whether it is possible to distinguish between the pervasive and chronic symptoms compared to those which may be addressed by assessment and treatment. Divalproex sodium in migraine prophylaxis: a dose-controlled study. About 2 billion people worldwide have been treated for pain with this agent, which is a µ opioid receptor agonist, as well as weak presynaptic reuptake inhibition of norepinephrine and serotonin (like venlafaxine, duloxetine, or milnacipran). Ergotamine is a pure arterial vasoconstrictor. The spectrum of abortive medications is covered extremely well in some of the comprehensive textbooks about headaches and migraines, including the role of opioids.4-6 A selective list of FDA-approved agents are highlighted in Table 1. METHODS Retrospective file review on 35 patients with dysautonomia and 35 sex and Glasgow coma scale score matched controls. You can change your cookie settings at any time. Please add updates@practicalpainmanagement.com to your address book to ensure delivery. We have also anecdotally looked at small numbers of patients with painful disorders like trigeminal neuralgia, complex regional pain syndrome (CRPS), and other pain flare-ups and they seem to also respond to propofol (unpublished data). Krusz JC, Belanger J. Some of the most common methods include: Epworth Sleepiness Scale. August 2003. The potentiation of narcotic analgesics with phenothiazines. Controlling blood pressure 3. Krusz JC. Muscle relaxants 6. Read our Privacy and Data Protection page for more information. Krusz JC, Longmire DR. Tramadol in the treatment of headaches. September 1996. Headaches after Traumatic Brain Injury was developed by Kathleen R. Bell, MD, Jeanne Hoffman, PhD, and Thomas Watanabe, MD, in collaboration with the Model Systems Knowledge Translation Center. Dr Silver is employed by the Walton Centre for neurology and neurosurgery where he runs the Headache Service, investigating and treating severe and refractory headache disorders.  His research interests include non-headache manifestations of migraine and other headache disorders and non-invasive neuro-stimulation and injection therapies for the treatment of headache disorders. Brain injury may be caused by a direct blow to the head, but shaking may also cause damage. Treatment patterns of isolated benign headache in US emergency departments. Glutamate, with its subtypes of receptor families, will be an active area of research and, hopefully, treatment. OBJECTIVES To better establish the clinical features, natural history, clinical management, and rehabilitation implications of dysautonomia after traumatic brain injury, and to highlight difficulties with previous nomenclature. The bottom line on preventative therapy for post-TBI headaches and migraines is to look for comorbidities that are present along with the headaches and to treat with an agent that can reduce the migraine frequency and severity and the comorbid clinical state. Besides these FDA-approved medications, virtually all of the anticonvulsants (we much prefer the phrase "neuronal stabilizing agents") have been tried in small trials, which are usually open label in nature. More data are available for the treatment of cluster headaches, status migrainosus, or analgesic rebound headaches.37 We frequently use dexamethasone (2-4 mg every 8-12 hours, as needed) for severe, refractory migraines along with IV MgSO4. It can be given alone, or combined with either antiemetics or IV corticosteroids. A brain injury is damage that causes the destruction or deterioration of brain cells. Removing clotted blood 2. More than half of the patients (57%) responded to valproate sodium treatment and the lower efficacy may be due to the nature of the chronic headache population treated in this study.53, We went over our initial study data and extracted 23 cases of bona fide status migrainosus from our initial published study sample treated with IV valproate sodium in the headache clinic.50 This very difficult-to-treat migraine population responded similarly as the refractory migraineurs, but needed a higher dose of valproate sodium (1,017 mg) and a longer treatment time (73 min vs 50 min). Jenkins et al. September 1998. Compounds that block the NMDA sub-family of glutamate receptors either have low potency (dextromethorphan or memantine) or they have higher potency and a narrow therapeutic index (ketamine).64. CSF glutamate levels in chronic migraine. June 2007. JC Krusz, J Cagle, D Daniel, VB Scott-Krusz. Dr Silver treats occipital nerve blocks for headache disorders, multiple cranial nerve blocks for headache disorders, cranial botulinum toxin (Botox) treatment for migraine and headache treatment, non-invasive stimulation (vagal nerve stimulation (gammaCore), trigeminal nerve stimulation (cefaly) and transcranial magnetic stimulation (eNeura) for the non-drug management of headache disorders and facial pain. This field is for validation purposes and should be left unchanged. New Orleans, Louisiana. Bell R, Montoya D, Shuaib A, Lee MA. This can sometimes lead to brain damage, which can be temporary or permanent. Sodium valproate has a prophylactic effect in migraine without aura. Therefore, all my information is anecdotal and I rarely use it alone but, instead, often use it after other agents. May 1998. Migraine-specific abortive therapy centers on the triptan family of compounds. JC Krusz, J Cagle. A traumatic brain injury (TBI), also known as an intracranial injury, is an injury to the brain caused by an external force. Ensuring adequate oxygen flow to the brain 2. As you can imagine, agents that have worked successfully, perhaps many times before, might not work in the next particular situation and so we always have a "game plan" for the next agent. Muscle spasm and pain as distinguished from migraines were rated by patients using a VAS every 15 minutes. IV tramadol: very efficacious treatment for pain and headache in the outpatient clinic. Intravenous valproate sodium in the treatment of refractory migraine headaches. Therefore the best advice when treating mental symptoms in a patient with a brain injury is to be symptom-specific and to use the same drug you would for someone without a brain injury. – Occupational Therapist Kate Meads gives an expert’s guide. Other authors have published results from their own clinics, showing that dexamethasone was indeed effective in their migraine and status migraine populations.38,39 This is not necessarily followed by an oral taper. Part 1 of this series described the biomechanics and pathophysiology of traumatic brain injuries, as well as their symptoms: post-concussion syndrome, post-traumatic headache, and migraine. Anticoagulants 3. Very few of the patients had to be retreated. 32nd Annual Scientific Meeting of the American Pain Society. After researching the literature, we found no mention of this agent in the treatment of migraines. According to Seifert, there are approximately 3.8 million sports-related concussions occurring each year, providing unique treatment challenges for medical personnel.3 The presence of new onset or persistent headache following an injury often complicates return-to-play decisions. It caused speculation as to the role this receptor might play in migraines. For the person or their family, there are several effects and much to learn on the road to recovery. What is vocational rehabilitation? Antidepressants 5. Abortive migraine therapy in the office with dexamethasone and prochlorperazine. Chronic pain sufferers are using our pain specialist directory to find pain specialists in your area. 47th Annual Scientific Meeting of the American Headache Society. Intravenous magnesium sulfate in the treatment of headaches. Results showed that headache severity diminished from 7.9 on VAS to 3.2 (P<.001). There is a growing body of evidence that a blockade of central dopamine receptor systems can enhance anti-nociception or the pain-relieving analgesic properties of opioids.27-29 One study of neuropathic pain suggested that bupropion might decrease neuropathic pain via an effect on presynaptic reuptake of dopamine.30 These properties might explain the ability of dopamine blockers, like metoclopramide or droperidol, to reduce migraine headaches—an effect we and others have noted in the clinic setting in the treatment of migraines. The pharmacologic treatment of acute migraine headaches. Ketamine, an agent specifically active against NMDA-type glutamate receptors in subanesthetic doses, has been little studied thus far, but may have theoretical implications for preventing chronic migraines. Schwartz TH, Karpitskiy VV, Sohn RS. Mauskop A, Altura BT, Cracco RQ, Altura BM. Indeed, one small study involving 6 children described the development of severe daily migraine-like headaches during cancer treatment.36 All patients had received daily doses of ondansetron and had a personal or family history of migraines, which may have placed them at risk of developing ondansetron-associated migraine-type headaches. Levetiracetam (Keppra) as prophylaxis for resistant headaches. (DSM III) in 1980, and since that time a great deal of knowledge has accumulated about the characteristics of post-traumatic symptomatology, the epidemiology of PTSD, and assessment and treatment of individuals suffering from this disorder. Baclofen IV in the clinic: effective treatment for muscle spasm pain and migraines. Alternatively, please fill out this form with a summary of your enquiry and we'll get back to you. Mauskop A, Altura BT, Cracco RQ, Altura BM. Migraine-type headaches in children receiving chemotherapy and ondansetron. Taylor BK, Joshi C, Uppal H. Stimulation of dopamine D2 receptors in the nucleus accumbens inhibits inflammatory pain. Since then, topiramate (Topamax) has been approved for migraine prophylaxis and one of its mechanisms of action is on GABA-A receptors. Seifert TD. May 2013: Abstract 382. Tramadol has been available in the United States for a number of years and has been used in Europe for more than 30 years. In the author's practice, we successfully have used these, as well as droperidol intravenously (IV) in the clinic (in small doses). Multiple Sleep Latency Test. Tampa, Florida. Krusz JC. Depending on the severity of injury, a family caregiver or friend may need to help implement the following approaches: 1. Zonisamide in the treatment of headache disorders. Krusz JC. Helsinki, Finland. Jones J, Pack S, Chun E. Intramuscular prochlorperazine versus metoclopramide as single-agent therapy for the treatment of acute migraine headache. Krusz JC. 7th European Federation of Neurological Societies. 7th Congress European Federation of Neurological Societies. Klapper JA. Klapper J. Post-traumatic headaches, often considered to be extremely difficult to treat, are actually easier to treat than most people realize if you pay attention to the parameters outlined in this article. Acute migraine treatment with droperidol: a randomized, double-blind, placebo-controlled trial. It seems as if virtually every combination of IV medications at our disposal has been tried or given in our clinic at one time or another. The second part of this series specifically addresses the treatment of PTH and does not claim to be comprehensive. A severe head injury can result in pressure being placed on the brain because of bleeding, blood clots or a build-up of fluid. Formal trials of IV lidocaine to treat acute migraine headache were published some time ago. Once again, anxiety, akathisia, and somnolence were rated as severe in 30% of patients, presumably due to the high doses employed. New Orleans, Louisiana. We have used this agent routinely in the clinic as a mild sedative prior to epidural steroid and facet nerve blocks in a conscious sedation manner. 64th Annual Meeting of the American Academy of Neurology. Only four medications are FDA approved for this indication: topiramate (Topamax), valproate sodium, propranolol, and timolol (the last of which is available as an optic solution primarily, and is very hard to find in tablet form). 9th European Federation of Neurological Societies Annual Meeting. When TBI migraines become disabling to one's lifestyle and occur more frequently than 3 times per week despite successful treatment with triptans or other migraine-specific therapies, it may be time to think about suppressive or prophylactic therapy. report that dopaminergic imaging can be used t We use cookies to enhance your experience on our website.By continuing to use our website, you are agreeing to our use of cookies. A series of bitesize webcasts designed to deliver concise and interesting updates, conversations and presentations on a range of topics, brought to you by our specialist lawyers and featuring some special guest speakers – Find out more. There is very little literature on the use of corticosteroids to treat migraines. While head injuries are one of the most common causes of death and disability in the United States, many patients with head injuries are treated and released from the emergency department after receiving treatment. Yet both groups required additional rescue treatment with analgesics (57%-79%) after initial treatment with an antiemetic.34 Another ED study compared the efficacy of IV MgSO4 with prochlorperazine in acute headache patients. There is substantial literature on the use of IV magnesium for migraines and cluster headaches.19-22 The original studies by Mauskop and colleagues studied ion-sensitive Mg++ electrodes to measure ionized magnesium, a technique not commonly available. Krusz JC. Methods: A total of 100 individuals with persistent post-traumatic headache attributed to mild traumatic brain injury were enrolled between July 2018 and June 2019. Cluster headache flare-ups and pain flare-ups like trigeminal neuralgia and CRPS have also been treated in the clinic.72,73 This is a powerful, non-toxic form of treatment for many difficult pain and headache flare-ups. In my opinion, the ideal headache clinic would offer a large number of IV services and be staffed by nurses trained in IV therapy and monitoring with pulse oximetry. The rise in popularity of e-scooters – what is the legal position in the UK? If you require immediate assistance, please call one of the switchboard numbers on our Contact page. FDA warns pregnant women to not use certain migraine prevention medicines. In our study, we treated 79 patients with IV tramadol. This suggested that we were not only clinically efficient but, on a cost basis, an aggressive clinic treatment of headache was less expensive than treatment in the emergency department (ED) as well. Intravenous magnesium sulfate rapidly alleviates headaches of various types. In addition, magnesium augments serotonin, which may be a direct means of blocking migraines. The injured person's eyes may remain closed, and the person may not show signs of awareness. Managing Post-Traumatic Headaches After Traumatic Brain Injury - VHL HealthSheet #41359_VA traumatic brain injury (TBI) is a sudden jolt to your head that changes the way your brain works. Krusz JC, Daniel D, Cagle J. IV tramadol for treating refractory migraines. We always have a patient acknowledge this for any treatment, oral or IV, and document this in their chart and on paper. Dr Silver offers invaluable insight into simple assessments of and treatment for fatigue that are commonly overlooked and explores other treatable symptoms arising from brain injury including poor cognition, sleep difficulties, dizziness and mood disturbance. What is a cognitive disorder after a traumatic brain injury? Considering the evidence that excitatory amino acids like glutamate are the "bad guys" in promoting nociception in general—and hyperalgesia and possibly allodynia—it is not surprising that agents, which antagonize this system might have utility in reducing pain and headache symptoms. Flores JA, El Banoua F, Galan-Rodriguez B, Fernandez-Espejo E. Opiate anti-nociception is attenuated following lesion of large dopamine neurons of the periaqueductal grey: critical role for D1 (not D2) dopamine receptors. Ziprasidone as prophylaxis for chronic daily headaches. Krusz, JC. As we have used IV ketamine in the clinic for more than 12 years, we have presented our data for IV ketamine for treating refractory headaches and pain several times.67,68 This is an ongoing study, which includes post-TBI migraines and headaches (with and without pain) and may be the largest database for migraine, cluster, chronic daily headache, and rare subtypes like paroxysmal hemicrania, hemicrania continua, and trigeminal neuralgia with migraines.69,70. The starting dose is 0.625 mg of IM droperidol, repeated after 20 to 30 minutes, and once again if needed. Headaches and migraines that occur after a TBI can be treated in any number of ways by healthcare practitioners. The patient can be kept in hospital overnight for observation, and then discharged if there are no further obvious medical injuries. Intravenous valproate sodium in the treatment of migraine headaches in the headache clinic. Therefore, we have a compounding pharmacy make up a sterile, neutral pH solution for use in the headache and pain clinic. Specific Measurable Achievable Relevant Timed goals and patient’s involvement in goal setting allows the clear orientation of the rehabilitation process and en… New Orleans, Louisiana. Many people forget that the pharmacologic profile of DHE is predominantly that of a venoconstrictor, as well as a relatively mild arterial constrictor. When we think of preventative therapy, it is wise to think about co-morbid post-concussion symptoms. Stop football…save brains: a point counterpoint discussion. He is involved in a number of national and international treatment trials in the field of headache and lead the headache research team at the Walton Centre. Jensen R, Brinck T, Olesen J. If migraines are present >2 to 3 times per week, it may be wise to consider a suppressive or prophylactic medication (see next section). Triptans can be used in conjunction with antiemetics (metoclopramide [Reglan], ondansetron [Zofran], promethazine [Phenergan], etc), and perhaps anti-inflammatory compounds. Krusz JC, Cagle J, Cammarata D. IV lidocaine: effective treatment for refractory migraines in the clinic. This is based on a study of 202 migraine patients. Psychosis after traumatic brain injury (TBI) is a relatively uncommon condition that presents both clinical and conceptual challenges. Mathew NT, Kailasam J, Meadors L, Chernyschev 0, Gentry P. Intravenous valproate sodium (Depacon) aborts migraine rapidly: a preliminary report. Krusz JC, Cagle J. Efficacy of IV lidocaine to treat pain and headache flareups in the outpatient clinic. All of the same agents have also been shown, at least in open-label trials, to reduce migraines and other headaches.56. Some headache and pain physicians think that neuropathic pain, chronic daily headaches, and migraines are, underneath it all, very similar in their biochemical underpinnings with respect to cellular mechanisms. Join a support group. There are so many different combinations of pain presentations (eg, refractory post-TBI migraines/headaches with pain and with nausea, or accompanying muscle spasms, burning). The authors noted that all the children responded to stopping the medication and starting treatment with standard anti-migraine therapy. Wang SJ, Silberstein SD, Young WB. Register now and get your name in front of these patients! The future of aggressive pain and headache treatment of TBI-related headaches will reside in the sphere of the specialist's clinic. A traumatic brain injury (TBI) is an injury that has occurred as a result of trauma to the head. Traumatic events that can result in PTSD fall into … Don't drive under the influence of alcohol or drugs, including prescription medications that can impair the ability to drive. Long-term use of steroids has its own side effect profile. Traumatic brain injury is defined as a traumatically induced structural injury and/or physiological disruption of brain function as a result of an external force that is indicated by new or worsening of at least 1 of the following clinical signs, immediately after the event: TBI can be classified based on severity (ranging from mild traumatic brain injury [mTBI/concussion] to severe traumatic brain injury), mechanism (closed or penetrating head injury), or other features (e.g., occurring in a specific location or over a widespread area). Increased attention to traumatic brain injury (TBI) has raised renewed interest in one of its consequencespost-traumatic headaches (PTH). Treatment of primary headache disorders with intravenous valproate: initial outpatient experience. I had originally published data with the oral form of the medication in treating headaches74 and was impressed by its ability to treat chronic headaches and migraines. Droperidol treatment of status migrainosus and refractory migraine. A search of the literature surprisingly revealed very little data to support its use in the treatment of acute or refractory migraines. At the end of treatment, migraines were absent in 24 patients.79. The IV preparation of tramadol turned out to be very efficacious, very well tolerated, rapidly treated refractory migraines and mixed headaches, and gave me another tool to use in the clinic when other agents failed.75 Our most recent accumulated data were presented this year. PTSD was first officially recognized in the Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. Access to the PPM Journal and newsletters is FREE for clinicians. Some of the triptans are available in faster delivery systems like injectable and nasal spray. A third study, however, found that valproate sodium was significantly less useful than prochlorperazine (Compazine) in the ED for headache pain (9 mm vs 64.5 mm, respectively) and nausea symptoms (35.5 mm vs 2 mm, P<0.001).52 A different study treated mostly chronic daily headaches, chronic TTH, and unclassifiable chronic headaches (67%), with just over 30% episodic migraines. Headache Update Annual Meeting. Fewer than 50% had successful resolution with ketamine.65 In this study the dose of ketamine was low, but more work needs to be done with this specific blocker of NMDA glutamate receptor subtypes. FDA. I have used IV lidocaine, with pulse oximetry monitoring, in the clinic for many years for the treatment of migraine, headache, and pain flare-ups. I strongly suggest that advanced cardiovascular life support–trained staff and a crash cart with oxygen and medications are in the clinic treatment area. Krusz JC, Robbins L. Traumatic brain injury. 32nd Annual Scientific Meeting of the American Pain Society. Ketamine IV - for CRPS, TN/TMD and other neuropathic pain in the outpatient pain clinic. A reformulated diclofenac potassium preparation (Cambia), with very rapid absorption kinetics, is also FDA indicated for mild to moderate migraine. Off-label use of medication is perfectly legitimate as long as the clinician explains that to the patient. I have listed all of the IV treatments to be described in the following sections in Table 3, which are based on my clinical experience. American Academy of Pain Management Annual Meeting. This is based on the notion that the use of both agents was somehow synergistic. Intravenous sodium valproate versus prochlorperazine for the emergency department treatment of acute migraine headaches: a prospective, randomized, double-blind study. In this episode, Emma Lyons and Dr Silver discuss the origins of fatigue after traumatic brain injury as well as the potential treatable causes. Magnesium has primary effects as a physiologic antagonist to calcium. Compared with the treatments commonly available in the ED, the outpatient clinic can offer a wider variety of effective and definitive treatments and, thus, offer patients a maximum degree of success for control of their intractable pain symptoms. A TBI often damages the front part of your brain, which is the part of the brain used for thinking and memory. Most often these have the characteristics of migraines, migrainous headaches, and mixed tension-type headaches (TTH) and migraines, as was discussed in Part 1 of this series.1 There have been a number of recent articles in medical journals that have renewed the debate about TBI, including an articl… While every injury is different, there are two main types of brain injury: traumatic brain injury (TBI) and acquired brain injury (ABI). Our study examined 63 patients with migraine, and muscle spasm and pain who were given 5 to 10 mg of IV baclofen at intervals of 10 to 15 minutes. It was noted that some patients who had migraines at the time of their blocks would comment on eradication of the migraine before the block was performed, but after propofol was given. The author's clinic compiled a track record in treating refractory headache and pain patients using IV medication therapy. Dr Silver qualified in medicine in 1989 and trained to registrar level in general medicine prior to specialising in neurology. In severe cases, a doctor might recommend surgical interventions to treat tremors after brain injury. Intravenous propofol: unique effectiveness in treating intractable migraine headaches. Seat belts and airbags. One study administered ketamine intranasally to migraine patients who had pronounced and disabling aura. Increased attention to traumatic brain injury (TBI) has raised renewed interest in one of its consequences—post-traumatic headaches (PTH). I formulated a sterile IV preparation to treat headaches and pain. Practical Pain Management is a Remedy Health Media, LLC web property. Ketamine in an outpatient setting: effective treatment for neuropathic pain syndromes. Nociceptive pain, peripheral and central sensitization, windup, long-term potentiation, and neuroplasticity are concepts basic to the expression and maintenance of these disorders. Intravenous valproate sodium in the treatment of daily headache. A trial of metoclopramide vs sumatriptan for the emergency department treatment of migraines. Our initial data with migraines77 have since grown in numbers and types of migraines treated78,79 and these include post-TBI migraines with severe muscle spasms. The fields of pain and headache management use common terminologies to describe these processes. Krusz JC, Scott VB, Belanger J. IV Droperidol as a treatment for acute migraine headache. Originally, it was noted serendipitously to help migraine headaches when it was being used for management of blood pressure and cardiac rhythm disorders. King MA, Bradshaw S, Chang AH, Pintar JE, Pasternak GW. Sodium valproate has a prophylaxis effect in migraine: a double-blind study vs placebo. Emergency treatment of intractable migraine. Comparisons of this protocol against "typical" treatment with meperidine (75 mg) and promethazine (25 mg) showed similar efficacy with significantly fewer side effects in the DHE/metoclopramide group,41 making it very useful for office-based treatment of migraines. Clinical data with the oral form of this neuronal stabilizing agent were the first available anywhere in the treatment of refractory migraine headaches,71 and this agent has a unique mechanism of action that effectively blocks high-voltage calcium channels—another major activity of many neuronal stabilizing agents. BACKGROUND: Headache is among the most common persistent symptoms after mild traumatic brain injury (mTBI). Montreal, Canada: June 2000. This term would be used in an all-inclusive fashion and under its umbrella all medical, psychological and other diagnoses from post-tbi would be included. The Pain Clinic, Tenerife, Canary Islands. June 2011: Abstract 15. Hopewell CA, Krusz JC, Thomson JA. Consultant Neurologist Dr Nicholas Silver gives an insight into treatment for fatigue, cognition, sleep, dizziness and mood disturbance. American Headache Society Annual Meeting. Post-traumatic stress disorder (PTSD) can develop after a very stressful, frightening or distressing event, or after a prolonged traumatic experience. Krusz JC, Scott VB, and Belanger J. American Headache Society 49th Annual Meeting. In many ways, IV magnesium sulfate (MgSO4) is sort of an "opening shot" for intractable headaches, both TBI migraines and not. Memantine for migraine and tension-type headache prophylaxis. Memantine for treatment of cognitive deficits after traumatic brain injury. Currently available treatments have limited efficacy. Silberstein SD, Young WB, Mendizabal JE, Rothrock JF, Alam AS. Common neurocellular and neurotransmitter pathways may explain the clinical expression of both neuropathic pain and migraine and associated hyperalgesia and central sensitization.63 On the treatment side of things, why is it that medications with completely different structures but similar mechanisms of action (propofol and topiramate, each of which act on GABA-A receptors) both reduce migraines, other headaches, and pain? Another small study evaluated the same protocol in a headache clinic against IV ketorolac and found the DHE protocol to result in a greater degree of pain improvement (P=0.31) and better function clinically (P=0.057).42 Various IV protocols available for clinic use were subsequently summarized by the same author.43. Just as two people are not exactly alike, no two brain injuries are exactly alike. Preventing further injury to the head or neck. Blockade of this system has definite implications for reducing neuropathic pain disorders. The average dose of valproate was 720 mg, given IV over about 50 minutes (100-200 mg every 5-10 minutes).47 Another study investigated the use of valproate sodium (loading dose 15 mg/kg, followed by 5 mg/kg every 8 hours) in initial treatment of chronic daily headache, transformed migraine, and analgesic overuse headaches.51 The authors stated that headache improvement was reported by 80% of the patients treated with IV valproate sodium, especially if other agents were not effective. May 2008. It also blocks N-methyl-D-aspartic acid (NMDA)–type glutamate excitatory amino acid activity, and nitric oxide synthesis and release—all of which are factors in migraine pathophysiology or maintenance. Klapper JA, Stanton JS. 2,5 Interestingly, several researchers have reported that post-traumatic headache is more common after concussion/mTBI than after severe TBI. You may have difficulty doing the same things that you did before the TBI. Post-TBI migraines, when accompanied by cognitive difficulties, have been shown to respond to the treatment memantine (Namenda), officially on the market only for management of dementia.12,13 However, many studies, primarily from Europe, have used this agent for various pain conditions off label, and we have used it as an agent to help with cognition after TBI.14, Antidepressants, particularly the serotonin-norepinephrine reuptake inhibitors, can help depression and anxiety, but they can also reduce pain and migraines post-TBI. The principles of drug treatment in somebody with a brain injury are outlined in Table 2. In our search for additional IV agents to use in the clinic for intractable migraines, we turned to this compound and presented an initial open-label study in poster form.47 Our results showed an impressive reduction in migraine severity, both in this initial trial and in subsequent studies. Cammarata D, Krusz JC. Krusz JC, Cagle J, Cammarata D. IV ketamine: effective therapy in the clinic for refractory migraines. DHE can be given IV or IM and has a 10- to 14-hour half-life. Ketorolac versus DHE and metoclopramide in the treatment of migraine headaches. Medication in other categories (so-called antipsychotic agents) have also been used to suppress migraines (eg, ziprasidone) and can be very useful in post-concussion headaches accompanied by irritability, mood instability, and sleep disorders.15. Renew Your Subscription and List Your Practice for Free! Many of the neuronal stabilizing agents include this mechanism of action. 3. Valproate sodium has been a popular migraine preventive. It consists of three parts: Acute treatment of post-TBI headaches using migraine-specific therapy, prophylactic therapy to suppress post-TBI headaches, and interventional treatments used in our outpatient headache clinic. IV baclofen for treating migraines accompanied by severe muscle spasm in an outpatient setting. Kaube H, Herzog J, Kaufer T, Dichgans M, Diener HC. For example, the author published the first data on migraine and neuropathic pain management treated with oxcarbazepine, levetiracetam, and zonisamide8-10 soon after they were officially released as seizure medications. Baclofen is a GABA-B receptor agonist, a unique mechanism of action. Cammarata D, Krusz JC. This is a cost- and time-effective mode of treating intractable pain and headaches. Both agents are compatible in the same IV bag (unpublished observations). 2. More studies are in progress. This month, our author tackles treatment of TBI headaches. Follow these tips to reduce the risk of brain injury: 1. You can find further information regarding our expertise, experience and team on our Personal Injury page. This small study (36 patients) found prochlorperazine to be statistically more effective at reducing pain than magnesium (90% vs 56%, respectively) with fewer side effects.35 One comment is that the dose of the MgSO4 was rather low at 1 g compared to our clinic IV doses of 2 g or greater. Unger J, Cady RK, Farmer-Cady K. Understanding migraine: treatment options. Gallagher RM. A moderate head injury is defined as loss of consciousness for between 15 minutes and six hours, or a period of post-traumatic amnesia of up to 24 hours. Triptans act specifically on serotonin (5HT)-1B and 1D receptors. Other agents in this large group were also studied for migraines, chronic daily headaches, and neuropathic pain by the same author.11 Unfortunately, in the vast majority of these studies the industry chose not to study the medication formally in a double-blind, placebo-controlled fashion. Athens, Greece: September 2005. Mauskop A, Altura BM. Is intravenous lidocaine clinically effective in acute migraine? The agency now reports that these agents are contraindicated in pregnant women for the prevention of migraine headaches.7 The β-blocker propranolol is often tried as initial prophylaxis therapy. 8th World Congress. It uses surgically implanted electrodes to send high-frequency signals to the thalamus, the structure in the brain that controls involuntary movements. 15th Congress of the International Headache Society. Krusz JC. Helmets. April 2012: Abstract 3780. Soon thereafter, other open-label studies, including our own, began to show up in the literature48-50 documenting efficacy of valproate sodium IV in treating migraines. Relieving pressure in the skull Medications These medications may include, but are not limited to: 1. Sports concussion and associated post-traumatic headache. July 1999. Accessed May 6, 2013. Also, ergotamine is fraught with the possibility of rebound migraines and headaches (now termed "medication overuse headache"), whereas DHE does not have this property. Anti-anxiety medications 2. Traumatic Brain Injury (TBI) is a disruption in the normal function of the brain that can be caused by a blow, bump or jolt to the head, the head suddenly and violently hitting an object or when an object pierces the skull and enters brain tissue. This promises to be a fascinating 15 minute bitesize session for all involved in working with those who have sustained brain injury. Krusz JC, Nett RB. We undertook a formal open-label study in the headache clinic to treat refractory migraines unresponsive to usual abortive approaches. Post-concussion syndrome (PCS), or post-concussive syndrome, refers to the lingering symptoms following a concussion or a mild traumatic brain injury (TBI).. Two studies found poorer outcome in the lidocaine-treated patients than with DHE, chlorpromazine treatment IV,57 or against placebo.58 The response to IV lidocaine was better in chronic daily headache in two retrospective studies.59,60 We have re-explored IV lidocaine for treatment of refractory migraines and have shown some promising data.61,62 However, this was an off-label use of lidocaine and, due to its ability to block neuropathic pain, it may play a roll in the treatment of refractory migraine post TBI. Washington, DC. Ondansetron, a 5-hydroxytriptamine type 3 receptor antagonist, is a very powerful antiemetic often used in the management of chemotherapy-induced nausea and vomiting. Stimulants Rehabilitation T… Of course, we make every effort to use one medication at a time and to carefully document the percentage of pain reduction of that single agent. Divalproex sodium (Depakote), as an enteric-coated preparation, was approved in 1994 for oral use in the prophylaxis of migraines in the United States. Intravenous lignocaine (lidocaine) infusion for the treatment of chronic daily headache with substantial medication overuse. This might include anxiety, depression, bipolar-like symptoms, seizures, high blood pressure, irritability, poor sleep, and mood swings. Treatment trials of psychotropics in brain-injured patients are lacking. 1-4 Studies to date have documented that anywhere from 30-90% of individuals who sustain a mTBI develop post-traumatic headache. The original IV DHE protocol to treat refractory migraine headaches was introduced in 1986 by Professor Raskin and it became the mainstay of inpatient and in-clinic treatments.40 Typically, DHE (1 mg) is given every 8 hours with IV metoclopramide 10 mg for 2 to 3 days. IV baclofen: treatment for refractory migraines and daily headaches C0-morbid with muscle spasm in the outpatient clinic. Proceedings of the National Academy of Sciences , … August 2007. I use it in an intrathecal sterile form (Gablofen) for epidural and facet blocks, but a commercially available IV form is not available in the United States. Webinar recording: Stewarts Soundbites Episode 12 – Rental Properties after Serious Injury; Obstacle or Opportunity? Peres MFP, Zukerman E, Soares C, Augusto S, Alonso EO, Santos BFC, Faulhaber MHW. Richter PA, Burk MP. Semenchuk MR, Davis B. Efficacy of sustained-release bupropion in neuropathic pain: an open-label study. Repetitive intravenous dihydroergotamine as therapy for intractable migraine. Animal experiments seemed to support this idea, but human studies are not at all conclusive on this point.24 I've looked for evidence of this, but it is almost non-existent; nausea is a prominent symptom accompanying headache. Oxcarbazepine as migraine prophylaxis. It was the first anticonvulsant molecule to be found useful in treating migraines in a prophylactic manner.44-46 An IV version of valproate sodium (Depacon) was developed and was used for treatment of seizures. 27th Annual Scientific Meeting, American Pain Society. American Academy of Pain Management Annual Meeting. Often, the response is short-lived (12-48 h), which buys time for other treatments to be put in place. Traumatic brain injury. Intravenous lignocaine infusions for severe chronic daily headache. An older ED study using IM prochlorperazine compared with metoclopramide found the former to be more reliable in reducing headache to the endpoint of the study (1 hour). The paradigm is to treat very slowly, so as to saturate the Na+ channels and obtain the best possible blockade. But there is always a risk that parts of treatment such as physical or occupational therapy might lead to new injuries or make existing symptoms or injuries worse if not done properly. Robbins L, Conidi FX. Orlando, Florida. Coronado, McGuire, Faul, Sugerman, Pearson. The agent has been used successfully in the clinical setting as an adjunctive medication for intractable vomiting associated with prolonged migraines (dosage: 2-4 mg IV). Miami, Florida: April 2005. Thus, keeping doses quite low (around 2 mg total) can be very effective and I have quite a number of patients who use IM droperidol at home as rescue medication for their migraines—either with migraine-specific therapy or to avoid a trip to the ED. May 2013: Abstract 378. Berlin, Germany. Abortive therapy centers on the notion that the use of corticosteroids to treat very slowly, so as the! And disabling aura 0.625 mg of IM droperidol, repeated after 20 to 30 minutes, milnacipran... 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