In thinking about the upcoming American Headache Society Annual Scientific Meeting in June, our clinic staff has been thinking about what interesting or new information we could offer to present at the conference. This is an important conference in the headache world, a mixture of scientific research and real-world clinical information and ideas. We were all able to attend a few years ago when it was local, in Boston. This year it is being held in San Diego, with many opportunities to provide interesting and informational posters about our work.
In a flurry of activity, we submitted 6 abstracts (!) for poster to the conference. I’d like to share a few of the ideas we are presenting.
Botox and behavior changes: We have 2 patients with developmental disabilities in our clinic with chronic migraine and neuralgia. They are both medically complex and have undergone a previous neurosurgical intervention (VP shunt, Chiari decompression). They both have tried a number of medications and interventions to decrease their headache and pain. These patients have significant baseline behavioral discontrol and self-injurious behaviors, presumably related to pain. These behaviors include hitting and banging their heads, scratching their heads and faces, and general irritability. After they each underwent several Botox for chronic migraine treatments, there was a notable decrease in migraine and neuropathic pain, and significant decrease in self-injurious behavior. As the Botox started wearing off (commonly around 10-11 weeks post-procedure), the self-injurious behavior returned. For patients with developmental disability, it is often difficult to discern the cause of their distress. Self-report is difficult and unreliable and often headache pain episodes are identified by observation of behavioral changes and irritability. A reduction in headache pain significantly reduced these behaviors and the distress felt by the patient and their caregivers. This was an unexpected and pleasant outcome that we feel needs to be shared with the headache community.
Safety and efficacy of short duration lidocaine infusion for NDPH: We have a fairly large population (25%) in our tertiary headache clinic of adolescents with new daily persistent headache (NDPH). These patients have very limited effective treatment options. I have posted a number of times about the care and challenges of these patients. I have also reported about treatment with short duration lidocaine infusions for them. Our hope was that lidocaine infusions, so helpful for patients with chronic pain, would also be helpful for NDPH patients (also a chronic pain condition). We submitted an abstract about our findings of the safety, toleration and effectiveness of the lidocaine infusions for NDPH. The idea of using lidocaine infusions for chronic pain is not new, but there are just a few papers out there about using it for teens with NDPH. We focused on reporting on the teenagers, age 11-17 years. We chose to look at patients undergoing their very first lidocaine infusion. We do have a number of patients who have the infusion every 3-4 months routinely, and subsequent infusion data was not include in this review. There were 20 patients included, and only those with NDPH diagnosis.
- Safety and tolerance: 30% of patients experienced a mild side effect during infusion, which resolved using our standard protocol (hold infusion, apply oxygen, restart infusion after resolution at slower rate). There were no severe or significant side effects, and no patient experienced any side effects after infusion was completed.
- Efficacy: There was minimal improvement in overall headache pain. However, 25% of patients reported improvement in symptoms and/or overall functioning and these results were maintained for at least 1 month.
For patients with limited options, short duration lidocaine infusion does offer some hope for improvement in headache, overall functioning and quality of life. The results were either improvement, or no improvement. None of the patients experienced a worsening of their condition, which is often the case with standard headache treatment and NDPH. Most patients who felt benefit have returned for further infusions, gained even more improvement, and have not returned to their original baseline. As my patients often tell me, ‘I can tolerate the headache- it’s the other symptoms that make it hard to cope.’
Endogenous Modulation and Central Sensitization in New Daily Persistent Headache (NDPH) in Children, preliminary findings: This is a basic science research initiative evaluating potential modulatory systems in NDPH patients, by looking at central sensitization, inflammatory markers, effects of low-dose Naltrexone, and comparing the neuroimaging of kids with NDPH and healthy controls. Recruitment and data collection is ongoing, with participants involved over a 6 months period. The current sample includes 40 subjects. There have been a modest number of subjects who reported benefit from low-dose naltrexone, and unlike previous literature, there have been more adverse effects among NDPH patients. Both sensory and lab testing is in process. On imaging, there has been decreased functional connectivity between thalamus and cerebellum and between angular gyrus and frontal gyri. That means there is less ability for these patients to inhibit pain and pain responses. There is more to come over time. There is so little information about NDPH out there, anything that would help elucidate the condition can help point the way to more effective treatments.
Botox and young migraineurs: I have also been looking at our data for our young chronic migraineurs, who were fortunate enough to receive insurance approval for Botox therapy under the age of 18. I currently have a group of 15 patients who started their Botox at age 17 or younger (youngest age 14). I was not able to get an abstract together to share the data at the AHS conference but I do plan to write up and publish it, to support our efforts in obtaining insurance approval. Results range from minimal improvement (3) to 95% reduction (2), with most patients clustered around 50-60% improvement. For most patients that improvement starts after the very 1st procedure; in adults it tends to take 2 procedures to start seeing noticeable results. These results are very promising. The kids are tolerating the procedure just fine, without a lot of drama or distress. They do especially well after the initial procedure because they know what to expect and they know it helps them. I admit that I really enjoy those visits.
That’s it for current updates. I enjoy sharing new and interesting information but most of all I love to work towards improving life for my patients.
HeadFirst PNP 