Safety and Efficacy of IV Lidocaine in the Treatment of Children and Adolescents With Status Migraine

Effectiveness of Lidocaine Infusion Versus Valproate Infusion for Pediatric Status Migrainosus

OBJECTIVE

To compare the efficacy (as measured by time to resolution of pain) and safety of valproate infusion and lidocaine infusion in the treatment of pediatric status migrainosus.

METHODS

We conducted a single-center retrospective cohort study from March 2014 to June 2021 evaluating children and adolescents who received a lidocaine or sodium valproate infusion for the treatment of status migrainosus. During the study period, lidocaine infusion was exclusively used before March 2016, whereas sodium valproate infusion was exclusively used afterward.

RESULTS

A total of 31 patients received lidocaine and 63 received sodium valproate infusion. Patients in the lidocaine group achieved significantly faster control of pain with median hours to pain free of 11.7 (interquartile range, 3.8-32.3) hours compared with 43.4 (interquartile range 13.8-68.7) hours in the valproate group (P = .002). At discharge, 21 of 31 (67.7%) of patients receiving lidocaine were pain-free compared with 26 of 59 (44.1%) of patients receiving valproate (P = .03). There were significantly more infusion interruptions of valproate compared with lidocaine for various patient-related factors (16/63, 25.4% vs 1/31, 3.2%; P = .009). More adverse effects were observed with valproate (42/63, 67%) compared with lidocaine (1/31, 3.2%; P < .001). The significant difference in hours to pain control persisted after adjustment for sex, race, age, BMI, presence of comorbidities, and pain score at admission. All patients in both groups completed the infusions and were discharged from the hospital.

CONCLUSIONS

Intravenous lidocaine infusion is associated with superior pain control and a better safety profile compared with intravenous sodium valproate infusion in status migrainosus.

Intraoperative application of low-dose dexmedetomidine or lidocaine for postoperative analgesia in pediatric patients following craniotomy: a randomized double-blind placebo-controlled trial

Background

Postoperative pain is a common occurrence in pediatric patients following craniotomy, often leading to negative outcomes. Intravenous dexmedetomidine and lidocaine are commonly used adjuvant medicines in general anesthesia to reduce perioperative opioid consumption and relieve postoperative pain in adults. While they show promise for use in pediatrics, the evidence of their application in pediatric craniotomy patients is limited. Therefore, we aimed to compare the effects of dexmedetomidine and lidocaine on postoperative pain in pediatric patients following craniotomy.

Methods

We conducted a randomized, double-blind, single-center trial on children scheduled for craniotomy. The 255 recruited participants aged 1-12 years were randomly assigned to intraoperatively receive a loading intravenous dose of either dexmedetomidine 1 μg·kg-1 or lidocaine 2 mg·kg-1 or normal saline for 15 min followed by dexmedetomidine 0.5 μg·kg-1·h-1 or lidocaine 1 mg·kg-1·h-1 or normal saline until the sutures of endocranium were completed. The primary outcome was the cumulative sufentanil consumption within 24 h post-surgery.

Results

A total of 241 patients were included in the statistical analysis. The primary outcome did not show any significant differences among the three groups (median (IQR) lidocaine group: 3.36 (1.32-5.64) μg vs. dexmedetomidine group: 3.12 (1.36-6.39) μg vs. control group 3.46 (1.77-7.62) μg, p = 0.485). Among the secondary outcomes, there was a statistically significant but small reduction in sufentanil consumption within 2 h, postoperative FLACC/WBFS/NRS pain scores within 4 h after surgery and postoperative Ramsay sedation scores in dexmedetomidine group (p < 0.05). Regarding postoperative complications, the incidence of electrolyte disturbance within 24 and 48 h after surgery was significantly higher in control group compared to the other two groups. There were no significant differences in intraoperative opioid consumption, postoperative frequency of remedy medication, or length of hospitalization among the three groups. No adverse events related to lidocaine or dexmedetomidine were observed.

Conclusions

There were no significant differences in the primary outcome among the three groups. Although dexmedetomidine showed some benefits in reducing postoperative opioid consumption within the first 2 h and pain intensity within the first 4 h post-surgery, these findings should be interpreted with caution. Further research is required to comprehensively assess the outcomes and determine the optimal administration strategy.

Clinical Trial Registration

[http://www.chictr.org.cn/index.aspx], identifier [ChiCTR1800019411].

Systemic Lidocaine Infusions for Pediatric Patients with Cancer-Related Pain

Pediatric patients with cancer experience significant distress from both treatment and cancer-related pain. Careful selection of an analgesic regimen should be based upon individual patient factors, including the level of pain, response to therapy, and physiologic profile. Refractory pain is a therapeutic dilemma frequently encountered in the pediatric cancer setting. Systemic lidocaine infusions have been described as both safe and efficacious, as prior studies show patients reporting decreased pain scores and improved quality of life after lidocaine treatment. Given the favorable side effect profile of lidocaine, it has the potential to be considered for analgesia in the setting of refractory pain. This review discusses the use of systemic lidocaine infusions for analgesia in pediatric oncology patients with cancer-related pain.

Mechanism-Based Pharmacological Treatment for Chronic Non-cancer Pain in Adolescents: Current Approaches and Future Directions

Chronic non-cancer pain in pediatrics is a widespread phenomenon that affects about 20% of adolescents (10-19 years old). Although interdisciplinary pain treatment programs, which often include pharmacological treatment, have emerged as the standard of care in management of this patient population, evidence regarding an optimal treatment is lacking. The efficacy and safety profiles of pharmacological treatments used to help adolescents suffering from chronic non-cancer pain remain understudied. This lack of evidence may increase polypharmacy and the risk of drug interactions and adverse events. This review examines evidence for the use of pharmacological treatments prescribed to treat chronic pain in adolescents (10-19 years old), with a focus on mechanism-based pharmacology. The objectives of this review are to: (a) review the evidence for mechanism-based pharmacological treatments for chronic non-cancer pain in adolescents and (b) describe the pharmacological agents that are commonly prescribed to manage chronic pain in adolescents, including dosage information, mechanism, and potential adverse effects. Pharmacological treatments should be used carefully with adolescents, ideally within an interdisciplinary treatment program that will incorporate physical rehabilitation, integrative medicine/active mind-body techniques, psychology, and global efforts to normalize daily activities.

Intravenous Lidocaine and Ketamine Infusions for Headache Disorders: A Retrospective Cohort Study

Introduction

The use of lidocaine (lignocaine) and ketamine infusion in the inpatient treatment of patients with headache disorders is supported by small case series. We undertook a retrospective cohort study in order to assess the efficacy, duration and safety of lidocaine and ketamine infusions.

Methods

Patients admitted between 01/01/2018 and 31/07/2021 were identified by ICD code and electronic prescription. Efficacy of infusion was determined by reduction in visual analog score (VAS), and patient demographics were collected from review of the hospital electronic medical record.

Results

Through the study period, 83 infusions (50 lidocaine, 33 ketamine) were initiated for a headache disorder (77 migraine, three NDPH, two SUNCT, one cluster headache). In migraine, lidocaine infusion achieved a ≥50% reduction in pain in 51.1% over a mean 6.2 days (SD 2.4). Ketamine infusion was associated with a ≥50% reduction in pain in 34.4% over a mean 5.1 days (SD 1.5). Side effects were observed in 32 and 42.4% respectively. Infusion for medication overuse headache (MOH) led to successful withdrawal of analgesia in 61.1% of lidocaine, and 41.7% of ketamine infusions.

Conclusion

Lidocaine and ketamine infusions are an efficacious inpatient treatment for headache disorders, however associated with prolonged length-of-stay and possible side-effects.

Status migrainosus inpatient treatment with eptinezumab (SMITE): study protocol for a randomised controlled trial

INTRODUCTION

Status migrainosus is a disabling complication of migraine, which frequently results in hospitalisation. For patients who fail to respond to simple analgesia, triptans and intravenous prochlorperazine or chlorpromazine, there are limited treatment options, and a paucity of high-quality evidence to guide clinical practice. Eptinezumab, an intravenous monoclonal antibody specific for the calcitonin gene-related peptide ligand which achieves maximal plasma concentration immediately following administration and may improve migraines from day one. Intravenous lignocaine is an anaesthetic medication used in treatment of status migrainosus, often requiring prolonged admissions and with potential cardiac adverse events. The aim of this study is to assess the efficacy and safety of eptinezumab in the treatment of status migrainosus in comparison to intravenous lidocaine.

METHODS AND ANALYSIS

Status migrainosus inpatient treatment with eptinezumab is a randomised, controlled, single-centre clinical trial conducted in a parallel design with an active comparator conducted in Melbourne, Australia. This study randomises forty patients (1:1) to receive either eptinezumab or an infusion of intravenous lignocaine for up to 5 days. It will assess the effect of eptinezumab compared with intravenous lignocaine in aborting status migrainosus, with the primary outcome of time from infusion until resolution of pain. It will explore several secondary measures including change in health resource utilisation, effect on patient reported outcomes of migraine disability and the safety and tolerability of each medication.

ETHICS AND DISSEMINATION

This study has been reviewed and approved by the Human Research Ethics Committee of Alfred Health, local reference number 443/21, and all participants will provide informed consent for participation in the trial and dissemination of results.

TRIAL REGISTRATION NUMBER

The trial registration number is ACTRN12621001616864. The results of this study will be disseminated through peer-reviewed journals, conference presentations and social media.

Dexmedetomidine vs. lidocaine for postoperative analgesia in pediatric patients undergoing craniotomy: a protocol for a prospective, randomized, double-blinded, placebo-controlled trial

Background

Postoperative pain is a common problem that occurs in pediatric patients following neurosurgery which may lead to severe complications. Dexmedetomidine is a commonly used adjuvant medicine in craniotomy owing to its sedative, amnestic, analgesic, and neuroprotective properties. Besides, studies suggest that lidocaine has similar effects on sedation, analgesia, and neuroprotection. Both two adjuvants can reduce postoperative pain after neurosurgery in adults. However, it is still unknown whether dexmedetomidine or lidocaine can reduce postoperative pain in children undergoing craniotomy, and if yes, which is a better medicine choice. Therefore, we aimed to compare the effect of dexmedetomidine vs. lidocaine on postoperative pain in pediatric patients after craniotomy.

Methods/design

We will perform a randomized (1:1:1), double-blind, placebo-controlled, single-center trial. Children aged 1–12 years scheduled for craniotomy will be eligible for inclusion. The 255 recruited participants will be stratified by age in two strata (1–6 years and 7–12 years), and then each stratum will be equally randomized to three groups: group D (infusion of dexmedetomidine [intervention group]), group L (infusion of lidocaine [intervention group]), and group C (infusion of normal saline [control group]). Patients will be followed up at 1 h, 2 h, 4 h, 24 h, and 48 h after surgery. The primary outcome will be total sufentanil consumption within 24 h after surgery.

Discussion

In this clinical trial, we expect to clarify and compare the postoperative analgesic effect of dexmedetomidine vs. lidocaine infusion on pediatric patients undergoing craniotomy. We believe that the results of this trial will provide more choices for postoperative analgesia for the pediatric population.

Trial registration

Chinese ClinicalTrials.gov ChiCTR1800019411. Registered on 10 November 2018

Lidocaine infusions and reduced opioid consumption-Retrospective experience in pediatric hematology and oncology patients with refractory pain

BACKGROUND

Despite a more robust experience with lidocaine infusions for pain management in adults and general pediatric population, there is limited evidence of efficacy of lidocaine infusions for pain management in patients with pediatric hematology and oncology diagnoses.

METHODS

Data pertaining to continuous intravenous lidocaine infusions prescribed between January 2009 and June 2019 were reviewed, including patients' demographic characteristics, hematology/oncology and pain diagnoses, concurrent pain medications, and lidocaine infusion dose regimens and duration. Pain scores and opioid consumption calculations based on morphine equivalent doses (mg/kg/day) of patient-controlled analgesia were collected 1 day before infusion (D1), during infusion (D2), and 1 day after infusion (D3).

RESULTS

The mean opioid consumption on D3 was significantly lower than that on D2 (p = .01). The pain scores on D3 were significantly lower than those on D1 when measured as average pain scores per 24 hours (p < .001) or as single pain scores immediately before and after infusions (p < .001). No significant associations were found between cumulative doses of lidocaine (loading dose plus total infusion dose) and either a decrease in the opioid consumption or a decrease in pain scores.

CONCLUSIONS

In this retrospective series of pediatric hematology and oncology cases, we report positive outcomes in reducing opioid consumption and pain scores after lidocaine infusions. Prospective investigations designed in a collaborative, multi-institutional fashion, including a variety of pediatric populations are needed to further investigate the efficacy of lidocaine infusions.

Intravenous lidocaine vs. NSAIDs for migraine attack in the ED: a prospective, randomized, double-blind study

PURPOSE

Although different forms of lidocaine are used for migraine attack headaches, the effect of intravenous lidocaine is still limited. This study aimed to investigate the effects of intravenous lidocaine infusion for the treatment of migraine attack headaches.

METHODS

A hundred patients with migraine attacks, aged between 18 and 65, were randomly divided into two groups. The lidocaine group (n = 50) received a 1.5 mg/kg lidocaine bolus and a 1 mg/kg infusion (first 30 min), followed by a 0.5 mg/kg infusion for a further 30 min intravenously. The non-steroidal anti-inflammatory drug (NSAID) group (n = 50) received 50 mg dexketoprofen trometamol and saline at the same volume as the lidocaine at the same time intervals intravenously. The Visual Analog Scale (VAS) pain scores, additional analgesia requirement, side effects, and revisits to the emergency department were recorded.

RESULTS

The VAS score was significantly lower in the lidocaine group than in the NSAID group for the first 20th and 30th minutes (p = 0.014 and p = 0.024, respectively). There was no difference between the VAS scores for the remaining evaluation times (p > 0.05). In terms of secondary outcomes, rescue medication requirement was not different between the two groups at both the 60th and 90th minutes (p > 0.05). However, the number of patients revisiting ED within 48-72 h was statistically less in the lidocaine group than in the NSAID group (1/50 vs. 8/50; p = 0.031).

CONCLUSION

Intravenous lidocaine may be an alternative treatment method for patients with migraine attack headaches in the emergency department.

Lidocaine Infusions for Pain Management in Pediatrics

Lidocaine is an amino amide with a well-established role as a local anesthetic agent. Systemic intravenous administration expands its clinical use to include acute and chronic pain circumstances, such as postoperative pain, neuropathic pain, postherpetic neuralgia, hyperalgesia, visceral pain, and centrally mediated pain. For refractory pain that has not responded to conventional therapy or if further escalation of treatment is prevented by contraindications or side effects to standard therapies, a continuous infusion of lidocaine may be considered as a single intervention or as a sequence of infusions. Here, we review and evaluate published data reflecting the use of lidocaine continuous infusions for pain management in the pediatric population.

Approach to Pediatric Intractable Migraine

PURPOSE OF REVIEW

Intractable migraine in children and adolescents is a significant cause of disability and decreased quality of life (QoL) in this population. Challenges include lack of unifying definition for intractable migraine, and limited data on best-practice management in this age group, with most current treatment pathways extrapolated from adult studies or expert consensus.

RECENT FINDINGS

A comprehensive approach in the evaluation and management of intractable migraine in this age group encompasses excluding secondary causes of headache; making an accurate diagnosis; identifying and appropriately managing modifiable risk factors; and initiating appropriate pharmacologic therapy to reduce disability, improve health-related quality of life, reduce risk of progression, and develop adaptive pain coping strategies. Several strategies for management of pediatric intractable migraine including use of acute medications, bridge therapy in outpatient setting, emerging therapies for preventive therapy, and a stepwise combination therapy for management of pediatric intractable migraine in emergency and inpatient setting are presented based on available clinical data, safety/tolerability, availability, cost-effectiveness, and expert consensus. This descriptive review of the available literature focuses on approach to therapy for acute intractable migraine in a pediatric population including outpatient, emergency department (ED), and inpatient management.

Inpatient Management of Migraine

Migraine is a frequently disabling neurologic condition which can be complicated by medication overuse headache and comorbid medical disorders, including obesity, anxiety and depression. Although most migraine management takes place in outpatient clinics, inpatient treatment is indicated for migraine refractory to multiple outpatient treatments, with intractable nausea or vomiting, need for detoxification from medication overuse (such as opioids and barbiturates), and significant medical and psychiatric disease. The goals of inpatient treatment include breaking the current cycle of headache pain, reducing the frequency and/or severity of future attacks, monitored detoxification of overused medications, and reducing disability and improving quality of life.

Migraine in children: presentation, disability and response to treatment

PURPOSE OF REVIEW

The current review presents findings from investigations of migraine in children. The presentation of pediatric migraine, related consequences, and medication treatments are reviewed.

RECENT FINDINGS

A number of advancements have been made in the study of the presentation, disability, and treatments for migraine in children. However, recent research suggests that not all approaches are equally effective in the treatment of migraine in children. Specifically, a recent study comparing pharmacological interventions found that preventive medications were not statistically more effective than placebo in children. Consistent findings showing clinically meaningful placebo response rates, shorter duration of headaches and other characteristic features (e.g. frontal, bilateral location) have been barriers to the design of randomized clinical trials in children and adolescents with migraine. Better understanding of treatment mechanisms for medication interventions is needed.

SUMMARY

Several migraine treatments have determined to be effective for use in children but few controlled studies have evaluated the effectiveness of medication treatments. Recent research suggests that preventive medications may not be more effective than placebo. Additional research is needed to evaluate the effectiveness of medication treatment in migraine headache care.