Primary Headache Disorders Part I- Migraine and the Trigeminal Autonomic Cephalalgias

Suboccipital steroid injection alone as a preventive treatment for cluster headache

BACKGROUND

Suboccipital steroid injection can be used as a preventive treatment for episodic and chronic cluster headache (CH). In recent studies, prophylactic treatment has been used in addition to suboccipital steroid injection. In this study, we aimed to investigate the effectivity of the sole use of rapid- and long-acting steroid injections without prophylactic treatment in patients with episodic and chronic CH.

METHODS

The retrospective study included 51 patients with episodic and chronic CH that underwent greater occipital nerve (GON) blockade with a single dose of rapid- and long-acting steroid injection without additional prophylactic treatment. The frequency, severity, and duration of attacks after GON blockade as well as the side effects and long-term outcomes were reviewed.

RESULTS

In 28 (54.9%) patients, no attack occurred after GON blockade and cluster bouts were aborted. Mean duration of attacks was 86.67 ± 37.45 min before the treatment. However, in the 23 patients that had at least one attack after GON blockade, the mean duration of attacks was 31.73 ± 36.10 min between post-treatment days 0-3, 29.35 ± 40.49 min between post-treatment days 4-10, 28.48 ± 42.17 min between post-treatment days 11-28, and 35.65 ± 46.55 min after the post-treatment day 28 (p < 0.001). Moreover, 10 (37.04%) out of 27 patients with episodic CH who periodically had one or two cluster bouts in a year had no CH attack at the time of the expected subsequent cluster bout.

CONCLUSION

GON blockade is a practical, reliable, and cost-effective treatment option for patients with episodic and chronic CH. Moreover, GON blockade is highly effective in reducing headache attacks and even aborting cluster bouts in CH patients without requiring additional prophylactic treatment.

To what extent are patients with migraine able to predict attacks?

Purpose

Premonitory symptoms (PSs) of migraine are those that precede pain in a migraine attack. Previous studies suggest that treatment during this phase may prevent the onset of pain; however, this approach requires that patients be able to recognize their PSs. Our objectives were to evaluate patients’ actual ability to predict migraine attacks based on their PSs and analyze whether good predictors meet any characteristic profile.

Patients and methods

This prospective, observational study included patients with migraine with and without aura. Patients’ baseline characteristics were recorded. During a 2-month follow-up period, patients used a mobile application to record what they believed to be PSs and later to record the onset of pain, if this occurred. When a migraine attack ended, patients had to complete a form on the characteristics of the episode (including the presence of PSs not identified prior to the attack).

Results

Fifty patients were initially selected. A final total of 34 patients were analyzed, recording 229 attacks. Of whom, 158 (69%) were accompanied by PSs and were recorded prior to the pain onset in 63 (27.5%) cases. A total of 67.6% of the patients were able to predict at least one attack, but only 35.3% were good predictors (>50% of attacks). There were only 11 cases in which a patient erroneously reported their PSs (positive predictive value: 85.1%). Good predictors were not differentiated by any specific clinical characteristic. However, a range of symptoms were particularly predictive; these included photophobia, drowsiness, yawning, increased thirst, and blurred vision.

Conclusion

A large majority of patients with migraine experienced a PS and were able to predict at least one attack. Besides, only a small percentage of patients were considered as good predictors; however, they could not be characterized by any specific profile. Nonetheless, when patients with migraine believed that they were experiencing PSs, they were frequently correct.

Intranasal Lidocaine for Acute Management of Primary Headaches: A Systematic Review

Intranasal lidocaine has been studied and recommended as an alternative in the management of acute headache. The objective of this systematic review was to evaluate the efficacy and safety of intranasal lidocaine in the acute management of primary headaches. The MEDLINE (1946 to May 2018), EMBASE (1974 to May 2018), Cochrane Central Register of Controlled Trials (2008 to May 2018), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to May 2018), and ClincialTrials.gov online databases were searched. Studies conducted in patients with acute primary headache were included if lidocaine was compared with placebo or alternative treatments, lidocaine dosing was specified, and patients' pain before and after treatment were clearly reported. Six studies met the inclusion criteria. Intranasal lidocaine demonstrated potential benefit over placebo in acute pain reduction and need for rescue medication only in the four studies deemed to be of poor quality, not in the two fair-quality studies. No study reported benefit in preventing headache recurrence or repeat visits to the emergency department. Lidocaine was associated with significantly higher rates of adverse events compared with placebo and may result in lower rates of patient satisfaction. There is insufficient evidence to support the use of intranasal lidocaine in acute management of primary headaches. Further research is warranted to better elucidate whether intranasal lidocaine has a role in the management of specific primary headache subtypes and whether there is an optimal regimen.