Treatment of refractory headache secondary to intracranial endovascular procedure by transcutaneous electrical nerve stimulation of the occipital nerve

The Medication Quantification Scale 4.0: An Updated Index Based on Prescribers' Perceptions of the Risk Associated With Chronic Pain Medications

To quantify risks associated with drug utilization in the real world for the treatment of chronic pain (CP), an index called the Medication Quantification Scale (MQS) was developed in 1992 in the United States and last updated in 2003. This study aimed to update, adapt to the contemporary Canadian context, and validate a revised version of the MQS (the MQS-4.0). Step 1: An expert committee adapted the MQS to the Canadian clinical practice context. Step 2: An update of risk weights given to medication subclasses was achieved using a prescriber survey (weights were derived from median 0-10 scores given to each subclass). Step 3: Construct validity of the MQS-4.0 was assessed after applying risk weights to the medication use profile of persons living with CP covered by public drug insurance plan. Thirty-six medication subclasses were included in the MQS-4.0. A total of 207 prescribers (physicians, pharmacists, and nurse practitioners) participated in the perception survey; 10.63% identified as pain specialists. When risk weights were applied to prescription claims (n = 9,122), the MQS-4.0 score was associated (P < .05) with the MQS-III score and variables associated with polypharmacy (eg, Charlson Comorbidity Index, number of prescribers or health care visits). This study provides an updated index intended for adult populations based on prescribers' perceptions of the risk associated with CP medications that can be useful for clinical practice and research among persons living with CP in Canada. It will, however, be relevant to verify whether similar risk weights are obtained in future pain specialist surveys. PERSPECTIVE: The MQS-4.0 is an update of the MQS used for quantifying the risk associated with the use of analgesics/coanalgesics. Adequate psychometrics properties were found.

Treatment of cognitive and mood disorders secondary to traumatic brain injury by the association of bilateral occipital nerve stimulation and a combined protocol of multisite repetitive transcranial magnetic stimulation and cognitive training: A case report

Purpose

Cognitive impairment secondary to traumatic brain injury (TBI) is difficult to treat and usually results in severe disability.

Method

A 48-year-old man presented with chronic refractory headaches and persistent disabling cognitive impairment after TBI. He was first treated with occipital nerve stimulation (ONS) implanted bilaterally to relieve headaches (8 years after the head trauma). Two years later, he was treated with a 6-week protocol combining repetitive transcranial magnetic stimulation (rTMS) delivered to multiple cortical sites (prefrontal cortex, language areas, and areas involved in visuo-spatial functions) and computerized cognitive training (CogT) (targeting memory, language, and visuo-spatial functions) to improve cognitive performance.

Results

Executive and cognitive functions (attention, ability to perform calculations, and verbal fluency) improved in association with pain relief after ONS (33-42% improvement) and then improved even more after the rTMS-CogT protocol with an additional improvement of 36-40% on apathy, depression, and anxiety, leading to a significant reduction in caregiver burden. The functional improvement persisted and even increased at 6 months after the end of the rTMS-CogT procedure (10 years after the onset of TBI and 2 years after ONS implantation).

Conclusion

This is the first observation describing sustained improvement in post-TBI refractory headache, depression, and cognitive impairment by the association of bilaterally implanted ONS and a combined procedure of multisite rTMS and CogT to target various brain functions.