Guía consenso sobre técnicas de infiltración anestésica de nervios pericraneales

Management of chronic migraine

Chronic migraine is a neurologic disorder associated with considerable disability, lost productivity, and a profound economic burden worldwide. The past five years have seen a dramatic expansion in new treatments for this often challenging condition, among them calcitonin gene related peptide antagonists and neuromodulatory devices. This review outlines the epidemiology of and diagnostic criteria and risk factors for chronic migraine. It discusses evidence based drug and non-drug treatments, their advantages and disadvantages, and the principles of patient centered care for adults with chronic migraine, with attention to differential diagnosis and comorbidities, clinical reasoning, initiation and monitoring, cost, and availability. It discusses the international guidelines on drug treatment for chronic migraine and evaluates non-drug treatments including behavioral and complementary therapies and lifestyle modifications. Finally, it discusses the management of chronic migraine in special populations, including pediatrics, pregnancy, and older people, and considers future questions and emerging research in the field.

Headache: What to ask, how to examine, and which scales to use. Recommendations of the Spanish Society of Neurology's Headache Study Group

INTRODUCTION

Headache is the most common neurological complaint at the different levels of the healthcare system, and clinical history and physical examination are essential in the diagnosis and treatment of these patients. With the objective of unifying the care given to patients with headache, the Spanish Society of Neurology's Headache Study Group (GECSEN) has decided to establish a series of consensus recommendations to improve and guarantee adequate care in primary care, emergency services, and neurology departments.

METHODS

With the aim of creating a practical document, the recommendations follow the dynamics of a medical consultation: clinical history, physical examination, and scales quantifying headache impact and disability. In addition, we provide recommendations for follow-up and managing patients' expectations of the treatment.

CONCLUSIONS

With this tool, we aim to improve the care given to patients with headache in order to guarantee adequate, homogeneous care across Spain.

Calcitonin gene-related peptide in migraine: from pathophysiology to treatment

INTRODUCTION

It has been observed in recent years that levels of such molecules as calcitonin gene-related peptide (CGRP) and, to a lesser extent, the pituitary adenylate cyclase-activating peptide are elevated during migraine attacks and in chronic migraine, both in the cerebrospinal fluid and in the serum. Pharmacological reduction of these proteins is clinically significant, with an improvement in patients' migraines. It therefore seems logical that one of the main lines of migraine research should be based on the role of CGRP in the pathophysiology of this entity.

DEVELOPMENT

The Spanish Society of Neurology's Headache Study Group decided to draft this document in order to address the evidence on such important issues as the role of CGRP in the pathophysiology of migraine and the mechanism of action of monoclonal antibodies and gepants; and to critically analyse the results of different studies and the profile of patients eligible for treatment with monoclonal antibodies, and the impact in terms of pharmacoeconomics.

CONCLUSIONS

The clinical development of gepants, which are CGRP antagonists, for the acute treatment of migraine attacks, and CGRP ligand and receptor monoclonal antibodies offer promising results for these patients.

Calcitonin gene-related peptide in migraine: from pathophysiology to treatment

INTRODUCTION

It has been observed in recent years that levels of such molecules as calcitonin gene-related peptide (CGRP) and, to a lesser extent, the pituitary adenylate cyclase-activating peptide are elevated during migraine attacks and in chronic migraine, both in the cerebrospinal fluid and in the serum. Pharmacological reduction of these proteins is clinically significant, with an improvement in patients' migraines. It therefore seems logical that one of the main lines of migraine research should be based on the role of CGRP in the pathophysiology of this entity.

DEVELOPMENT

The Spanish Society of Neurology's Headache Study Group decided to draft this document in order to address the evidence on such important issues as the role of CGRP in the pathophysiology of migraine and the mechanism of action of monoclonal antibodies and gepants; and to critically analyse the results of different studies and the profile of patients eligible for treatment with monoclonal antibodies, and the impact in terms of pharmacoeconomics.

CONCLUSIONS

The clinical development of gepants, which are CGRP antagonists, for the acute treatment of migraine attacks, and CGRP ligand and receptor monoclonal antibodies offer promising results for these patients.

Treatment of occipital neuralgia using onabotulinum toxin A

OBJECTIVES

To determine the effectiveness of botulinum toxin in a sample of patients diagnosed with greater occipital nerve neuralgia.

MATERIAL AND METHODS

Twenty-nine patients (28 females, 1 male) were treated for greater occipital nerve neuralgia with onabotulinum toxin type A; the Visual Analog Pain Scale was used to determine pain severity at treatment and again 12 weeks after application.

RESULTS

Average doses of onabotulinum toxin type A of 18.66±6.44 U per nerve and 35.96±12.89 U per patient were utilized. Average pain severity among the sample was 9.81±0.89 prior to botulinum toxin application and 3.68±2.31 points (p<0.0001) twelve weeks after application. Pain frequency decreased from 29.93±0.37 to 12.17±11.05 days with pain per month (p<0.0001). Six patients reported absence of pain after application (p=0.023). Dose did not correlate with the degree of clinical response observed, and no side effects were reported.

CONCLUSION

Our findings suggest onabotulinum toxin type A is a safe and effective treatment alternative for patients suffering from refractory greater occipital nerve neuralgia.

Headache: pregnancy and breastfeeding Recommendations of the Spanish Society of Neurology's Headache Study Group

INTRODUCTION

Headache is one of the most common neurological complaints, and is most frequent during reproductive age. As a result, we are routinely faced with pregnant or breastfeeding women with this symptom in clinical practice. It is important to know which pharmacological choices are the safest, which should not be used, and when we should suspect secondary headache. To this end, the Spanish Society of Neurology's Headache Study Grouphas prepared a series of consensus recommendations on the diagnostic and therapeutic algorithms that should be followed during pregnancy and breastfeeding.

DEVELOPMENT

This guide was prepared by a group of young neurologists with special interest and experience in headache, in collaboration with the Group's Executive Committee. Recommendations focus on which drugs should be used for the most frequent primary headaches, both during the acute phase and for prevention. The second part addresses when secondary headache should be suspected and which diagnostic tests should be performed in the event of possible secondary headache during pregnancy and breastfeeding.

CONCLUSIONS

We hope this guide will be practical and useful in daily clinical practice and that it will help update and improve understanding of headache management during pregnancy and breastfeeding, enabling physicians to more confidently treat these patients.

Migraine review for general practice

Migraine continues second among the world's causes of disability. Diagnosis is based on the history and clinical examination and imaging is usually not necessary. Migraine can be subdivided depending on whether there is an aura or not and based on the frequency of the headaches. The number of headache days determines whether the patient has episodic migraine or chronic migraine. Treating migraines can be done to treatment the migraine itself and to prevent its appearance. In this review we approach the migraine from a practical point of view with updated information.

Headache: pregnancy and breastfeeding. Recommendations of the Spanish Society of Neurology's Headache Study Group

INTRODUCTION

Headache is one of the most common neurological complaints, and is most frequent during reproductive age. As a result, we are routinely faced with pregnant or breastfeeding women with this symptom in clinical practice. It is important to know which pharmacological choices are the safest, which should not be used, and when we should suspect secondary headache. To this end, the Spanish Society of Neurology's Headache Study Group has prepared a series of consensus recommendations on the diagnostic and therapeutic algorithms that should be followed during pregnancy and breastfeeding.

DEVELOPMENT

This guide was prepared by a group of young neurologists with special interest and experience in headache, in collaboration with the Group's Executive Committee. Recommendations focus on which drugs should be used for the most frequent primary headaches, both during the acute phase and for prevention. The second part addresses when secondary headache should be suspected and which diagnostic tests should be performed in the event of possible secondary headache during pregnancy and breastfeeding.

CONCLUSIONS

We hope this guide will be practical and useful in daily clinical practice and that it will help update and improve understanding of headache management during pregnancy and breastfeeding, enabling physicians to more confidently treat these patients.

Nerve block as neuropathic pain treatment for the great auricular nerve neuropathy: A case report

OBJECTIVE/BACKGROUND

The great auricular nerve (GAN) is a major sensory branch of the cervical plexus. Painful great auricular neuropathy causes pain circumscribed to the inferior preauricular region, the jaw angle, the ventral pinna, and the mastoid region.

METHODS

We present a 46-year-old woman experiencing facial pain in the bilateral preauricular and infra-auricular region, constant, of abrasive quality without any other associated symptomatology that is triggered or aggravated with cephalic movements, cervical turn, mandibular movement, and palpation on the affected area.

RESULTS

Symptomatic treatment with analgesics, anti-inflammatories, and neuropathic preventive medications was ineffective. However, nerve block anesthetic treatment resulted in complete pain remission.

CONCLUSION

Great auricular neuropathy is an uncommon cause of facial pain; our case report is the first bilateral occurrence reported to date. It should be suspected in patients with circumscribed shooting or lancinating paroxysmal pain in the territory of the GAN. It is characterized by the aggravation of pain with cervical movements and complete relief after anesthetic blockade.

Clinical Characteristics and Therapeutic Results in a Series of 68 Patients with Occipital Neuralgia

OBJECTIVE

Cranial pain is a condition that has a negative impact on human lives, and occipital neuralgia is among its causes. This study aims to evaluate the clinical characteristics and therapeutic results of a series of patients with occipital neuralgia.

DESIGN

Prospective registry (observational study).

SETTINGS

Headache outpatient clinic in a tertiary hospital.

SUBJECTS

Sixty-eight cases.

METHODS

Demographic and nosological characteristics have been analyzed, as well as treatment response of occipital neuralgia. All patients were recruited between January 2008 and January 2018, and the diagnosis of occipital neuralgia was made according to the International Headache Society (International Classification of Headache Disorders) criteria being utilized at the time of diagnosis.

RESULTS

Sixty-eight patients were diagnosed with occipital neuralgia, which corresponded to 1.2% of the total number of patients (5,515) who visited our Headache Unit during the aforementioned period. Fifty-four (79.4%) of them were female. Baseline pain was present in 62 (91.1%) patients, and exacerbations in 42 (61.8%). Latency from onset (range) was 27.7 ± 56.1 (1-360) months.

CONCLUSIONS

Occipital neuralgia is an uncommon disorder in the sample explored. The prolonged latency between the onset of symptoms and diagnosis suggests that there should be an increased awareness of this disorder.

Botulinum toxin as a novel therapeutic approach for auriculotemporal neuralgia

OBJECTIVES/BACKGROUND

Auriculotemporal neuralgia is a rare headache disorder. Anesthetic nerve blockade seems to be effective in most cases; however, literature is scarce about the management of refractory cases.

METHODS

Case report.

RESULTS

We report a 44-year-old woman with migraine without aura presented with moderate-to-severe right temporoparietal headache. The pain was refractory to multiple pharmacological strategies, including intravenous analgesia. A more throughout examination lead to the diagnosis of auriculotemporal neuralgia and anesthetic nerve blocks were performed. Due to early pain recrudescence, botulinum toxin (BoNT) was tried with better and longstanding pain control.

CONCLUSION

BoNT may be a useful treatment option in refractory auriculotemporal neuralgia. The best approach is yet to be established; however, the "follow-the-pain" protocol may be a reasonable option.

[The efficacy of therapeutic nerve blocks in patients with cervicogenic headache]

AIM

To compare the efficacy of 2% articaine solution and 2% lidocaine solution used to perform therapeutic nerve blocks of the large occipital nerve in patients with cervicogenic headache.

MATERIAL AND METHODS

A randomized prospective comparative clinical study was conducted in two groups treated with articaine (n=22) or lidocaine (n=21). The therapeutic great occipital nerve blocks were performed on the 1st, 3d and 5th days of treatment. The efficacy of treatment was assessed by the pain intensity measured with the Visual Analogue scale (VAS) and the duration of individual pain paroxysms on the 5th and 10th days.

RESULTS

The baseline VAS pain intensity was 6.3±1.2 and 5.9±2.0 centimeters, whereas the duration of individual pain paroxysms was 7.8±2.3 and 9.1±2.8 hours in the articaine group and the lidocaine group, respectively. By the 5th day, there was a more dramatically decrease in VAS pain intensity and duration in the articaine group (up to 3.0±0.8 and 4.3±1.2 centimeters VAS (p<0.05)) compared to the lidocaine group (up to 1.9±0.6 to 4.8±1.3 hours (p<0.05)). By the 10th day, the pain intensity did not differ between groups (1.2±0.5 and 1.7±0.7 centimeters (p>0.05)). The duration of pain episodes was still lower in the articaine group (0.5±0.08 hours) compared to the lidocaine group (2.4±0.8 hours) (p<0.05).

CONCLUSION

Therapeutic large occipital nerve blocks with 2% solution of articaine show the significant decrease in pain intensity and duration of pain paroxysms in a short period of time for patients with cervicogenic headache.

Occipital osteomylelitis and epidural abscess after occipital nerve block: A case report

Occipital neuralgia is a paroxysmal jabbing pain in the distribution of the greater or lesser occipital nerves accompanied by diminished sensation in the affected area. Occipital nerve block is a common diagnostic and therapeutic tool used in the course of occipital neuralgia and is considered a safe treatment with few localized adverse events. Occipital nerve block is also indicated for cervicogenic and cluster headache and is often used as a rescue treatment for headaches not responding to conventional therapies. We describe a case of epidural abscess formation 16 days following occipital nerve block in a patient with no underlying medical conditions. This case report emphasizes the importance of strict aseptic technique to reduce infection rates in patients undergoing this procedure, despite the overall safety of occipital nerve block. Clinicians must remain aware of acute and late complications arising postprocedure for the safe practice of this technique.

Evidence and experience with onabotulinumtoxinA in chronic migraine: Recommendations for daily clinical practice

OnabotulinumtoxinA has been demonstrated to be effective as a preventive treatment in patients with chronic migraine (CM). Five years after the approval of onabotulinumtoxinA in Spain, the Headache Study Group of the Spanish Society of Neurology considered it worthwhile to gather a group of experts in treating patients with CM in order to draw up, based on current evidence and our own experience, a series of guidelines aimed at facilitating the use of the drug in daily clinical practice. For this purpose, we posed 12 questions that we ask ourselves as doctors, and which we are also asked by our patients. Each author responded to one question, and the document was then reviewed by everyone. We hope that this review will constitute a practical tool to help neurologists treating patients with CM.

Lacrimal Nerve Blocks for Three New Cases of Lacrimal Neuralgia

OBJECTIVE

Our aim was to report three new cases of lacrimal neuralgia and their response to superficial nerve blocks.

BACKGROUND

Lacrimal neuralgia has been recently described as a pain in the territory supplied by the lacrimal nerve, at the lateral upper eyelid and/or the adjacent area of the temple. The pain is typically accompanied by tenderness on palpation of the lacrimal nerve at the superoexternal angle of the orbit.

METHODS

Between January 2015 and June 2016, we prospective identified three cases of lacrimal neuralgia among the patients attending the Headache Unit in a tertiary hospital. Anesthetic blocks were performed in all cases by inserting a 30-G needle on the emergence of the nerve and injecting 0.5 cc of bupivacaine 0.5% subcutaneously.

RESULTS

Three women aged 44, 49, and 51 presented with pain in the territory supplied by the lacrimal nerve. Two of them localized their pain in a small area of the right temple, while the remaining patient had pain in the right upper lateral eyelid and a small area of the lower lateral eyelid. The pain was continuous in two patients and episodic with attacks lasting 48 hours in one patient. All patients had tenderness on palpation of the lacrimal nerve. Anesthetic blocks confirmed the diagnosis of lacrimal neuralgia and provided the patients with long-lasting pain relief.

CONCLUSIONS

Lacrimal neuralgia should be considered among the neuralgic causes of orbital and periorbital pain. Superficial nerve blocks may assist clinicians in the diagnosis and may also be a therapeutic option.