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How Can Neurologists Manage Pediatric Migraine?
OJAI, CA—Migraine headaches can be debilitating in children and adolescents and result in more missed days of school and poorer performance in the classroom, compared with children without migraine, according to an overview presented at the 10th Annual Winter Conference of the Headache Cooperative of the Pacific.
Understanding Pediatric Migraine
Pediatric migraine is defined as at least five attacks that fulfill the following criteria: headache attack lasting for two to 72 hours (untreated or unsuccessfully treated), headache with at least two of four characteristics (ie, unilateral location [though in children it is often bilateral], pulsating quality, moderate or severe intensity, and aggravation by or causing avoidance of routine physical activity), and headache accompanied by either nausea and vomiting or phonophobia and photophobia. It affects approximately 5% of children by age 10, making migraine five to 10 times more common than epilepsy in children. Chronic migraine, which entails headache on at least 15 days per month for at least three months, affects 0.6% of children between ages 5 and 12.
Pediatric migraine can have a different phenotype than adult migraine. The shortest duration for untreated or unsuccessfully treated attacks in adults is four hours, compared with two hours in children. In addition, migraines in children and adolescents tend to be bilateral.
Following puberty, there is a higher prevalence of migraine among young women and girls than among boys and young men, said Dr. Gelfand. Also, children with low socioeconomic status are nearly fourfold more likely to have chronic migraine than children from affluent backgrounds.
How to Take a Pediatric Headache History
A systematic approach to taking a headache history can be helpful, said Dr. Gelfand. When neurologists take a headache history, seating the child or adolescent in a central position near the clinican can help signal that the patient is going to be the primary person to provide the history. In addition, neurologists should set expectations for pediatric patients by explaining the questions they are going to ask about the child’s headaches.
Children are encouraged to share additional information about their headaches and to ask parents for help when necessary. Also, neurologists should hesitate to consider “not really” an answer to questions about the presence of symptoms such as nausea or movement sensitivity, because it often means “yes, but it is mild, and I can handle it and do not want to complain.”
Finally, when querying for sensitivity to light or sound, neurologists are advised to ask the following questions: During your headaches, do lights ever bother you? Do lights ever seem brighter than usual? Do lights ever make the headache worse? “For younger kids who might not be able to articulate sensitivity to light or sensitivity to sound, we may be able to infer those sensitivity symptoms from their behavior. Are they pulling the blankets up over their head or are they asking for the TV to be turned off? These are behaviors that their caregivers can report,” said Dr. Gelfand.
Acute Migraine Treatment
Acetaminophen and ibuprofen have been examined in randomized controlled trials that included children as young as 4. These drugs appear to be efficacious. In addition, the FDA has approved four triptans for acute treatment of pediatric migraine. Almotriptan was approved in 2009 for adolescents ages 12 to 17. In 2012, the FDA approved rizatriptan for children and adolescents ages 6 to 17. Finally, in 2015, zolmitriptan, a nasal spray, was approved for adolescents ages 12 to 17, as was a combination including naproxen and sumatriptan. Children with a history of peripheral vascular disease, stroke, and uncontrolled hypertension should not use triptans for the treatment of pediatric migraine.
In addition, Powers et al observed that amitriptyline and topiramate were no different from placebo for reducing headache frequency; approximately 60% of participants in all three study arms improved. The 361 children and adolescents involved in the study received a lot of headache education and counseling about medication overuse, and also received optimally dosed acute migraine medications, which may have contributed to the high rate of excellent outcomes, said Dr. Gelfand.
Preventative Strategies and Diet
A key component to preventive care in pediatric migraine is maintaining a healthy lifestyle. Neurologists should encourage patients to eat regular meals, get regular exercise and sleep, and stay consistently hydrated. Additionally, daily preventive treatment may include medications or supplements that are well tolerated. Cognitive behavioral therapy can also be beneficial.
Children and adolescents with migraine should avoid fasting, alcohol, or nitrate-containing meats such as hot dogs, some lunch meats, salami, and beef jerky. Chocolate, cheese, citrus, gluten, sugar, or dairy might not need to be avoided. Also, proper hydration can help control or prevent migraines. Pilot studies have shown that increased water intake decreases headache hours and severity. Spigt et al found that greater water intake resulted in a statically significant improvement in quality of life.
The Future of Pediatric Migraine Research
Sixty percent of patients will improve following treatment, but 40% of patients do not get better. In addition, “children who have continous headache and medication overuse have not been well studied, so we do not know what treatments might be most effective for them,
—Erica Tricarico
Suggested Reading
Qubty W, Gelfand AA. Psychological and behavioral issues in the management of migraine in children and adolescents. Curr Pain Headache Rep. 2016;20(12):69.
Spigt MG, Kuijper EC, Schayck CP, et al. Increasing the daily water intake for the prophylactic treatment of headache: a pilot trial. Eur J Neurol. 2005;12(9):715-718.
OJAI, CA—Migraine headaches can be debilitating in children and adolescents and result in more missed days of school and poorer performance in the classroom, compared with children without migraine, according to an overview presented at the 10th Annual Winter Conference of the Headache Cooperative of the Pacific.
Understanding Pediatric Migraine
Pediatric migraine is defined as at least five attacks that fulfill the following criteria: headache attack lasting for two to 72 hours (untreated or unsuccessfully treated), headache with at least two of four characteristics (ie, unilateral location [though in children it is often bilateral], pulsating quality, moderate or severe intensity, and aggravation by or causing avoidance of routine physical activity), and headache accompanied by either nausea and vomiting or phonophobia and photophobia. It affects approximately 5% of children by age 10, making migraine five to 10 times more common than epilepsy in children. Chronic migraine, which entails headache on at least 15 days per month for at least three months, affects 0.6% of children between ages 5 and 12.
Pediatric migraine can have a different phenotype than adult migraine. The shortest duration for untreated or unsuccessfully treated attacks in adults is four hours, compared with two hours in children. In addition, migraines in children and adolescents tend to be bilateral.
Following puberty, there is a higher prevalence of migraine among young women and girls than among boys and young men, said Dr. Gelfand. Also, children with low socioeconomic status are nearly fourfold more likely to have chronic migraine than children from affluent backgrounds.
How to Take a Pediatric Headache History
A systematic approach to taking a headache history can be helpful, said Dr. Gelfand. When neurologists take a headache history, seating the child or adolescent in a central position near the clinican can help signal that the patient is going to be the primary person to provide the history. In addition, neurologists should set expectations for pediatric patients by explaining the questions they are going to ask about the child’s headaches.
Children are encouraged to share additional information about their headaches and to ask parents for help when necessary. Also, neurologists should hesitate to consider “not really” an answer to questions about the presence of symptoms such as nausea or movement sensitivity, because it often means “yes, but it is mild, and I can handle it and do not want to complain.”
Finally, when querying for sensitivity to light or sound, neurologists are advised to ask the following questions: During your headaches, do lights ever bother you? Do lights ever seem brighter than usual? Do lights ever make the headache worse? “For younger kids who might not be able to articulate sensitivity to light or sensitivity to sound, we may be able to infer those sensitivity symptoms from their behavior. Are they pulling the blankets up over their head or are they asking for the TV to be turned off? These are behaviors that their caregivers can report,” said Dr. Gelfand.
Acute Migraine Treatment
Acetaminophen and ibuprofen have been examined in randomized controlled trials that included children as young as 4. These drugs appear to be efficacious. In addition, the FDA has approved four triptans for acute treatment of pediatric migraine. Almotriptan was approved in 2009 for adolescents ages 12 to 17. In 2012, the FDA approved rizatriptan for children and adolescents ages 6 to 17. Finally, in 2015, zolmitriptan, a nasal spray, was approved for adolescents ages 12 to 17, as was a combination including naproxen and sumatriptan. Children with a history of peripheral vascular disease, stroke, and uncontrolled hypertension should not use triptans for the treatment of pediatric migraine.
In addition, Powers et al observed that amitriptyline and topiramate were no different from placebo for reducing headache frequency; approximately 60% of participants in all three study arms improved. The 361 children and adolescents involved in the study received a lot of headache education and counseling about medication overuse, and also received optimally dosed acute migraine medications, which may have contributed to the high rate of excellent outcomes, said Dr. Gelfand.
Preventative Strategies and Diet
A key component to preventive care in pediatric migraine is maintaining a healthy lifestyle. Neurologists should encourage patients to eat regular meals, get regular exercise and sleep, and stay consistently hydrated. Additionally, daily preventive treatment may include medications or supplements that are well tolerated. Cognitive behavioral therapy can also be beneficial.
Children and adolescents with migraine should avoid fasting, alcohol, or nitrate-containing meats such as hot dogs, some lunch meats, salami, and beef jerky. Chocolate, cheese, citrus, gluten, sugar, or dairy might not need to be avoided. Also, proper hydration can help control or prevent migraines. Pilot studies have shown that increased water intake decreases headache hours and severity. Spigt et al found that greater water intake resulted in a statically significant improvement in quality of life.
The Future of Pediatric Migraine Research
Sixty percent of patients will improve following treatment, but 40% of patients do not get better. In addition, “children who have continous headache and medication overuse have not been well studied, so we do not know what treatments might be most effective for them,
—Erica Tricarico
Suggested Reading
Qubty W, Gelfand AA. Psychological and behavioral issues in the management of migraine in children and adolescents. Curr Pain Headache Rep. 2016;20(12):69.
Spigt MG, Kuijper EC, Schayck CP, et al. Increasing the daily water intake for the prophylactic treatment of headache: a pilot trial. Eur J Neurol. 2005;12(9):715-718.
OJAI, CA—Migraine headaches can be debilitating in children and adolescents and result in more missed days of school and poorer performance in the classroom, compared with children without migraine, according to an overview presented at the 10th Annual Winter Conference of the Headache Cooperative of the Pacific.
Understanding Pediatric Migraine
Pediatric migraine is defined as at least five attacks that fulfill the following criteria: headache attack lasting for two to 72 hours (untreated or unsuccessfully treated), headache with at least two of four characteristics (ie, unilateral location [though in children it is often bilateral], pulsating quality, moderate or severe intensity, and aggravation by or causing avoidance of routine physical activity), and headache accompanied by either nausea and vomiting or phonophobia and photophobia. It affects approximately 5% of children by age 10, making migraine five to 10 times more common than epilepsy in children. Chronic migraine, which entails headache on at least 15 days per month for at least three months, affects 0.6% of children between ages 5 and 12.
Pediatric migraine can have a different phenotype than adult migraine. The shortest duration for untreated or unsuccessfully treated attacks in adults is four hours, compared with two hours in children. In addition, migraines in children and adolescents tend to be bilateral.
Following puberty, there is a higher prevalence of migraine among young women and girls than among boys and young men, said Dr. Gelfand. Also, children with low socioeconomic status are nearly fourfold more likely to have chronic migraine than children from affluent backgrounds.
How to Take a Pediatric Headache History
A systematic approach to taking a headache history can be helpful, said Dr. Gelfand. When neurologists take a headache history, seating the child or adolescent in a central position near the clinican can help signal that the patient is going to be the primary person to provide the history. In addition, neurologists should set expectations for pediatric patients by explaining the questions they are going to ask about the child’s headaches.
Children are encouraged to share additional information about their headaches and to ask parents for help when necessary. Also, neurologists should hesitate to consider “not really” an answer to questions about the presence of symptoms such as nausea or movement sensitivity, because it often means “yes, but it is mild, and I can handle it and do not want to complain.”
Finally, when querying for sensitivity to light or sound, neurologists are advised to ask the following questions: During your headaches, do lights ever bother you? Do lights ever seem brighter than usual? Do lights ever make the headache worse? “For younger kids who might not be able to articulate sensitivity to light or sensitivity to sound, we may be able to infer those sensitivity symptoms from their behavior. Are they pulling the blankets up over their head or are they asking for the TV to be turned off? These are behaviors that their caregivers can report,” said Dr. Gelfand.
Acute Migraine Treatment
Acetaminophen and ibuprofen have been examined in randomized controlled trials that included children as young as 4. These drugs appear to be efficacious. In addition, the FDA has approved four triptans for acute treatment of pediatric migraine. Almotriptan was approved in 2009 for adolescents ages 12 to 17. In 2012, the FDA approved rizatriptan for children and adolescents ages 6 to 17. Finally, in 2015, zolmitriptan, a nasal spray, was approved for adolescents ages 12 to 17, as was a combination including naproxen and sumatriptan. Children with a history of peripheral vascular disease, stroke, and uncontrolled hypertension should not use triptans for the treatment of pediatric migraine.
In addition, Powers et al observed that amitriptyline and topiramate were no different from placebo for reducing headache frequency; approximately 60% of participants in all three study arms improved. The 361 children and adolescents involved in the study received a lot of headache education and counseling about medication overuse, and also received optimally dosed acute migraine medications, which may have contributed to the high rate of excellent outcomes, said Dr. Gelfand.
Preventative Strategies and Diet
A key component to preventive care in pediatric migraine is maintaining a healthy lifestyle. Neurologists should encourage patients to eat regular meals, get regular exercise and sleep, and stay consistently hydrated. Additionally, daily preventive treatment may include medications or supplements that are well tolerated. Cognitive behavioral therapy can also be beneficial.
Children and adolescents with migraine should avoid fasting, alcohol, or nitrate-containing meats such as hot dogs, some lunch meats, salami, and beef jerky. Chocolate, cheese, citrus, gluten, sugar, or dairy might not need to be avoided. Also, proper hydration can help control or prevent migraines. Pilot studies have shown that increased water intake decreases headache hours and severity. Spigt et al found that greater water intake resulted in a statically significant improvement in quality of life.
The Future of Pediatric Migraine Research
Sixty percent of patients will improve following treatment, but 40% of patients do not get better. In addition, “children who have continous headache and medication overuse have not been well studied, so we do not know what treatments might be most effective for them,
—Erica Tricarico
Suggested Reading
Qubty W, Gelfand AA. Psychological and behavioral issues in the management of migraine in children and adolescents. Curr Pain Headache Rep. 2016;20(12):69.
Spigt MG, Kuijper EC, Schayck CP, et al. Increasing the daily water intake for the prophylactic treatment of headache: a pilot trial. Eur J Neurol. 2005;12(9):715-718.
Migraine Increases the Risk of Perioperative Ischemic Stroke
Patients who undergo surgery have an increased risk of perioperative ischemic stroke if they have a history of migraine, according to a prospective study published January 10 in the BMJ. Surgical patients with a history of migraine also have an increased 30-day hospital readmission rate, compared with patients without migraine.
“Understanding this risk period offers unique opportunities to study ischemic stroke in migraine and might result in treatment considerations for patients at risk who are not undergoing surgical intervention,” said Matthias Eikermann, MD, PhD, Associate Professor of Anesthesia at Harvard Medical School in Boston, and colleagues. “An individual perioperative risk assessment for perioperative ischemic stroke in patients with migraine undergoing surgery may be crucial.” 
Dr. Eikermann and colleagues conducted a prospective hospital registry study that encompassed 124,558 patients who underwent surgery at Massachusetts General Hospital and two community hospitals in Massachusetts between January 2007 and August 2014. The researchers determined participants’ history of migraine and migraine aura status using ICD-9 diagnosis codes. The primary outcome was perioperative ischemic stroke within 30 days after surgery. The secondary outcome was hospital readmission within 30 days of discharge.
The mean age of participants was 52.6. Approximately 55% of patients were women. The investigators identified 10,179 (8.2%) patients with migraine, of whom 1,278 (12.6%) had migraine with aura. Compared with participants without migraine, migraineurs were more often female, were younger, and had an overall lower frequency of vascular risk factors.
Among the 124,558 patients who underwent surgery, the investigators observed 771 (0.6%) perioperative ischemic strokes. Of all patients with perioperative ischemic stroke, 89 (11.5%) had migraine. Among migraineurs, 18 (2.3%) had migraine with aura, and 71 (9.2%) had migraine without aura. Patients with migraine had an increased risk for perioperative ischemic stroke, compared with patients without migraine (adjusted odds ratio, 1.75). The risk of ischemic stroke was higher for patients with migraine with aura (adjusted odds ratio, 2.61), but also was apparent for migraine without aura (adjusted odds ratio, 1.62), compared with surgical patients without migraine.
Dr. Eikermann and colleagues predicted that 2.4 ischemic strokes would occur for every 1,000 surgical patients. This risk increased to 4.3 strokes for every 1,000 patients with migraine. Stratified by migraine with aura status, these numbers are 3.9 strokes for migraine without aura and 6.3 strokes for migraine with aura.
A total of 10,088 participants were readmitted to the hospital within 30 days. The 30-day hospital readmission rate was higher for patients with migraine than for those with no migraine (adjusted odds ratio, 1.31). Migraine with aura (adjusted odds ratio, 1.59) and migraine without aura (adjusted odds ratio, 1.27) were associated with a higher risk of 30-day hospital readmission, compared with patients without migraine.
“The use of high-dose vasopressors during surgery, as well a history of a possible right-to-left shunt, may represent modifiable risk factors for perioperative ischemic stroke in patients with migraine with aura,” said Dr. Eikermann. “Early detection of symptoms of stroke through close postoperative monitoring of patients at high risk should be crucial to optimize the value of perioperative care in patients with migraine.”
—Erik Greb
Suggested Reading
Timm FP, Houle TT, Grabitz SD, et al. Migraine and risk of perioperative ischemic stroke and hospital readmission: hospital based registry study. BMJ. 2017 Jan 10;356:i6635.
Patients who undergo surgery have an increased risk of perioperative ischemic stroke if they have a history of migraine, according to a prospective study published January 10 in the BMJ. Surgical patients with a history of migraine also have an increased 30-day hospital readmission rate, compared with patients without migraine.
“Understanding this risk period offers unique opportunities to study ischemic stroke in migraine and might result in treatment considerations for patients at risk who are not undergoing surgical intervention,” said Matthias Eikermann, MD, PhD, Associate Professor of Anesthesia at Harvard Medical School in Boston, and colleagues. “An individual perioperative risk assessment for perioperative ischemic stroke in patients with migraine undergoing surgery may be crucial.”
Dr. Eikermann and colleagues conducted a prospective hospital registry study that encompassed 124,558 patients who underwent surgery at Massachusetts General Hospital and two community hospitals in Massachusetts between January 2007 and August 2014. The researchers determined participants’ history of migraine and migraine aura status using ICD-9 diagnosis codes. The primary outcome was perioperative ischemic stroke within 30 days after surgery. The secondary outcome was hospital readmission within 30 days of discharge.
The mean age of participants was 52.6. Approximately 55% of patients were women. The investigators identified 10,179 (8.2%) patients with migraine, of whom 1,278 (12.6%) had migraine with aura. Compared with participants without migraine, migraineurs were more often female, were younger, and had an overall lower frequency of vascular risk factors.
Among the 124,558 patients who underwent surgery, the investigators observed 771 (0.6%) perioperative ischemic strokes. Of all patients with perioperative ischemic stroke, 89 (11.5%) had migraine. Among migraineurs, 18 (2.3%) had migraine with aura, and 71 (9.2%) had migraine without aura. Patients with migraine had an increased risk for perioperative ischemic stroke, compared with patients without migraine (adjusted odds ratio, 1.75). The risk of ischemic stroke was higher for patients with migraine with aura (adjusted odds ratio, 2.61), but also was apparent for migraine without aura (adjusted odds ratio, 1.62), compared with surgical patients without migraine.
Dr. Eikermann and colleagues predicted that 2.4 ischemic strokes would occur for every 1,000 surgical patients. This risk increased to 4.3 strokes for every 1,000 patients with migraine. Stratified by migraine with aura status, these numbers are 3.9 strokes for migraine without aura and 6.3 strokes for migraine with aura.
A total of 10,088 participants were readmitted to the hospital within 30 days. The 30-day hospital readmission rate was higher for patients with migraine than for those with no migraine (adjusted odds ratio, 1.31). Migraine with aura (adjusted odds ratio, 1.59) and migraine without aura (adjusted odds ratio, 1.27) were associated with a higher risk of 30-day hospital readmission, compared with patients without migraine.
“The use of high-dose vasopressors during surgery, as well a history of a possible right-to-left shunt, may represent modifiable risk factors for perioperative ischemic stroke in patients with migraine with aura,” said Dr. Eikermann. “Early detection of symptoms of stroke through close postoperative monitoring of patients at high risk should be crucial to optimize the value of perioperative care in patients with migraine.”
—Erik Greb
Suggested Reading
Timm FP, Houle TT, Grabitz SD, et al. Migraine and risk of perioperative ischemic stroke and hospital readmission: hospital based registry study. BMJ. 2017 Jan 10;356:i6635.
Patients who undergo surgery have an increased risk of perioperative ischemic stroke if they have a history of migraine, according to a prospective study published January 10 in the BMJ. Surgical patients with a history of migraine also have an increased 30-day hospital readmission rate, compared with patients without migraine.
“Understanding this risk period offers unique opportunities to study ischemic stroke in migraine and might result in treatment considerations for patients at risk who are not undergoing surgical intervention,” said Matthias Eikermann, MD, PhD, Associate Professor of Anesthesia at Harvard Medical School in Boston, and colleagues. “An individual perioperative risk assessment for perioperative ischemic stroke in patients with migraine undergoing surgery may be crucial.”
Dr. Eikermann and colleagues conducted a prospective hospital registry study that encompassed 124,558 patients who underwent surgery at Massachusetts General Hospital and two community hospitals in Massachusetts between January 2007 and August 2014. The researchers determined participants’ history of migraine and migraine aura status using ICD-9 diagnosis codes. The primary outcome was perioperative ischemic stroke within 30 days after surgery. The secondary outcome was hospital readmission within 30 days of discharge.
The mean age of participants was 52.6. Approximately 55% of patients were women. The investigators identified 10,179 (8.2%) patients with migraine, of whom 1,278 (12.6%) had migraine with aura. Compared with participants without migraine, migraineurs were more often female, were younger, and had an overall lower frequency of vascular risk factors.
Among the 124,558 patients who underwent surgery, the investigators observed 771 (0.6%) perioperative ischemic strokes. Of all patients with perioperative ischemic stroke, 89 (11.5%) had migraine. Among migraineurs, 18 (2.3%) had migraine with aura, and 71 (9.2%) had migraine without aura. Patients with migraine had an increased risk for perioperative ischemic stroke, compared with patients without migraine (adjusted odds ratio, 1.75). The risk of ischemic stroke was higher for patients with migraine with aura (adjusted odds ratio, 2.61), but also was apparent for migraine without aura (adjusted odds ratio, 1.62), compared with surgical patients without migraine.
Dr. Eikermann and colleagues predicted that 2.4 ischemic strokes would occur for every 1,000 surgical patients. This risk increased to 4.3 strokes for every 1,000 patients with migraine. Stratified by migraine with aura status, these numbers are 3.9 strokes for migraine without aura and 6.3 strokes for migraine with aura.
A total of 10,088 participants were readmitted to the hospital within 30 days. The 30-day hospital readmission rate was higher for patients with migraine than for those with no migraine (adjusted odds ratio, 1.31). Migraine with aura (adjusted odds ratio, 1.59) and migraine without aura (adjusted odds ratio, 1.27) were associated with a higher risk of 30-day hospital readmission, compared with patients without migraine.
“The use of high-dose vasopressors during surgery, as well a history of a possible right-to-left shunt, may represent modifiable risk factors for perioperative ischemic stroke in patients with migraine with aura,” said Dr. Eikermann. “Early detection of symptoms of stroke through close postoperative monitoring of patients at high risk should be crucial to optimize the value of perioperative care in patients with migraine.”
—Erik Greb
Suggested Reading
Timm FP, Houle TT, Grabitz SD, et al. Migraine and risk of perioperative ischemic stroke and hospital readmission: hospital based registry study. BMJ. 2017 Jan 10;356:i6635.
IV Ketamine May Be Effective as Subacute Treatment for Refractory Chronic Migraine
Ketamine may help to treat pain in patients with refractory chronic migraine, according to a case series published in the December 2016 Journal of Headache and Pain. IV ketamine treatment was associated with short-term improvement in pain severity in six of six patients with refractory chronic migraine.
“This study highlights the need for further research regarding new treatment options for patients who suffer daily consequences of refractory migraine and have failed many abortive and preventive medications,” said Clinton Lauritsen, MD, a Headache Fellow at Thomas Jefferson University Hospital in Philadelphia. 
Ketamine is a dissociative anesthetic that acts on glutamate binding sites at the N-methyl-D-aspartate (NMDA) receptor, as well as at opioid, monoaminergic, cholinergic, nicotinic, and muscarinic receptors. IV ketamine was previously studied in several refractory pain conditions, including complex regional pain. While intranasal ketamine reduced the severity of migraine aura in a small randomized trial, the use of IV ketamine has only been reported in case series. Krusz et al showed improvement in pain scores in patients who used IV ketamine for refractory migraine; few side effects were reported.
Inpatient IV Ketamine
To further investigate the effect of IV ketamine in patients with intractable migraine, Dr. Lauritsen and colleagues conducted a retrospective chart review study. The researchers identified six patients with refractory chronic migraine admitted to Mount Sinai Beth Israel Hospital in New York from 2010 through 2014 for treatment with continuous IV ketamine.
Patients were given a starting dose of 0.1 mg/kg/h that was increased by 0.1 mg/kg/h every three to four hours as tolerated until the target pain score of 3 out of 10 was achieved and maintained for at least eight hours. Subsequently, the infusion was decreased by 0.2 mg/kg/h every three to four hours until the infusion rate reached 0 mg/kg/h.
The dose of ketamine was increased until maximum response was achieved or undesirable side effects, including psychomimetic and dysphoric effects, developed. Researchers used the Visual Analogue Score (VAS) at admission and during follow-up. VAS scores at different ketamine infusion rates were assessed from nursing and infusion records. Pain response was defined as a reduction in the initial VAS to a score of 3 or less. In addition, researchers attempted to contact patients for a telephone follow-up; however, they were only able to reach two of the six patients. During the telephone interview, researchers administered a questionnaire.
Pain Relief Achieved
Results from the data revealed a median age of 36.5 years; 83% of the patients were women. All of the patients were Caucasian, and the median age of migraine onset was 17. The median duration of the disease was 17 years. The mean number of failed acute migraine treatments was 18, and the mean number of failed preventive medications was 25. Pre-treatment pain scores ranged from 9 to 10.
In this small case series, all six patients with refractory migraine met
Overall, IV ketamine relieved pain in patients with chronic migraine without substantial adverse effects. “However, future study of this benefit on short-term headache relief needs to be conducted in a placebo-controlled fashion,” said Dr. Lauritsen.
“It is biologically plausible that ketamine could be an effective treatment for intractable headache,” the researchers said. “Ketamine is an antagonist at NMDA receptors, blocking the excitatory action of glutamate, a neurotransmitter long implicated in the pathophysiology of migraine. Glutamate has been … implicated in induction of cortical spreading depression [and] activation of trigeminal nociceptive neurons [and may] play a role in central sensitization.”
—Erica Tricarico
Suggested Reading
Lauritsen C, Mazuera S, Lipton RB, Ashina S. Intravenous ketamine for subacute treatment of refractory chronic migraine: a case series. J Headache Pain. 2016;17(1)106-110.
Ketamine may help to treat pain in patients with refractory chronic migraine, according to a case series published in the December 2016 Journal of Headache and Pain. IV ketamine treatment was associated with short-term improvement in pain severity in six of six patients with refractory chronic migraine.
“This study highlights the need for further research regarding new treatment options for patients who suffer daily consequences of refractory migraine and have failed many abortive and preventive medications,” said Clinton Lauritsen, MD, a Headache Fellow at Thomas Jefferson University Hospital in Philadelphia.
Ketamine is a dissociative anesthetic that acts on glutamate binding sites at the N-methyl-D-aspartate (NMDA) receptor, as well as at opioid, monoaminergic, cholinergic, nicotinic, and muscarinic receptors. IV ketamine was previously studied in several refractory pain conditions, including complex regional pain. While intranasal ketamine reduced the severity of migraine aura in a small randomized trial, the use of IV ketamine has only been reported in case series. Krusz et al showed improvement in pain scores in patients who used IV ketamine for refractory migraine; few side effects were reported.
Inpatient IV Ketamine
To further investigate the effect of IV ketamine in patients with intractable migraine, Dr. Lauritsen and colleagues conducted a retrospective chart review study. The researchers identified six patients with refractory chronic migraine admitted to Mount Sinai Beth Israel Hospital in New York from 2010 through 2014 for treatment with continuous IV ketamine.
Patients were given a starting dose of 0.1 mg/kg/h that was increased by 0.1 mg/kg/h every three to four hours as tolerated until the target pain score of 3 out of 10 was achieved and maintained for at least eight hours. Subsequently, the infusion was decreased by 0.2 mg/kg/h every three to four hours until the infusion rate reached 0 mg/kg/h.
The dose of ketamine was increased until maximum response was achieved or undesirable side effects, including psychomimetic and dysphoric effects, developed. Researchers used the Visual Analogue Score (VAS) at admission and during follow-up. VAS scores at different ketamine infusion rates were assessed from nursing and infusion records. Pain response was defined as a reduction in the initial VAS to a score of 3 or less. In addition, researchers attempted to contact patients for a telephone follow-up; however, they were only able to reach two of the six patients. During the telephone interview, researchers administered a questionnaire.
Pain Relief Achieved
Results from the data revealed a median age of 36.5 years; 83% of the patients were women. All of the patients were Caucasian, and the median age of migraine onset was 17. The median duration of the disease was 17 years. The mean number of failed acute migraine treatments was 18, and the mean number of failed preventive medications was 25. Pre-treatment pain scores ranged from 9 to 10.
In this small case series, all six patients with refractory migraine met
Overall, IV ketamine relieved pain in patients with chronic migraine without substantial adverse effects. “However, future study of this benefit on short-term headache relief needs to be conducted in a placebo-controlled fashion,” said Dr. Lauritsen.
“It is biologically plausible that ketamine could be an effective treatment for intractable headache,” the researchers said. “Ketamine is an antagonist at NMDA receptors, blocking the excitatory action of glutamate, a neurotransmitter long implicated in the pathophysiology of migraine. Glutamate has been … implicated in induction of cortical spreading depression [and] activation of trigeminal nociceptive neurons [and may] play a role in central sensitization.”
—Erica Tricarico
Suggested Reading
Lauritsen C, Mazuera S, Lipton RB, Ashina S. Intravenous ketamine for subacute treatment of refractory chronic migraine: a case series. J Headache Pain. 2016;17(1)106-110.
Ketamine may help to treat pain in patients with refractory chronic migraine, according to a case series published in the December 2016 Journal of Headache and Pain. IV ketamine treatment was associated with short-term improvement in pain severity in six of six patients with refractory chronic migraine.
“This study highlights the need for further research regarding new treatment options for patients who suffer daily consequences of refractory migraine and have failed many abortive and preventive medications,” said Clinton Lauritsen, MD, a Headache Fellow at Thomas Jefferson University Hospital in Philadelphia.
Ketamine is a dissociative anesthetic that acts on glutamate binding sites at the N-methyl-D-aspartate (NMDA) receptor, as well as at opioid, monoaminergic, cholinergic, nicotinic, and muscarinic receptors. IV ketamine was previously studied in several refractory pain conditions, including complex regional pain. While intranasal ketamine reduced the severity of migraine aura in a small randomized trial, the use of IV ketamine has only been reported in case series. Krusz et al showed improvement in pain scores in patients who used IV ketamine for refractory migraine; few side effects were reported.
Inpatient IV Ketamine
To further investigate the effect of IV ketamine in patients with intractable migraine, Dr. Lauritsen and colleagues conducted a retrospective chart review study. The researchers identified six patients with refractory chronic migraine admitted to Mount Sinai Beth Israel Hospital in New York from 2010 through 2014 for treatment with continuous IV ketamine.
Patients were given a starting dose of 0.1 mg/kg/h that was increased by 0.1 mg/kg/h every three to four hours as tolerated until the target pain score of 3 out of 10 was achieved and maintained for at least eight hours. Subsequently, the infusion was decreased by 0.2 mg/kg/h every three to four hours until the infusion rate reached 0 mg/kg/h.
The dose of ketamine was increased until maximum response was achieved or undesirable side effects, including psychomimetic and dysphoric effects, developed. Researchers used the Visual Analogue Score (VAS) at admission and during follow-up. VAS scores at different ketamine infusion rates were assessed from nursing and infusion records. Pain response was defined as a reduction in the initial VAS to a score of 3 or less. In addition, researchers attempted to contact patients for a telephone follow-up; however, they were only able to reach two of the six patients. During the telephone interview, researchers administered a questionnaire.
Pain Relief Achieved
Results from the data revealed a median age of 36.5 years; 83% of the patients were women. All of the patients were Caucasian, and the median age of migraine onset was 17. The median duration of the disease was 17 years. The mean number of failed acute migraine treatments was 18, and the mean number of failed preventive medications was 25. Pre-treatment pain scores ranged from 9 to 10.
In this small case series, all six patients with refractory migraine met
Overall, IV ketamine relieved pain in patients with chronic migraine without substantial adverse effects. “However, future study of this benefit on short-term headache relief needs to be conducted in a placebo-controlled fashion,” said Dr. Lauritsen.
“It is biologically plausible that ketamine could be an effective treatment for intractable headache,” the researchers said. “Ketamine is an antagonist at NMDA receptors, blocking the excitatory action of glutamate, a neurotransmitter long implicated in the pathophysiology of migraine. Glutamate has been … implicated in induction of cortical spreading depression [and] activation of trigeminal nociceptive neurons [and may] play a role in central sensitization.”
—Erica Tricarico
Suggested Reading
Lauritsen C, Mazuera S, Lipton RB, Ashina S. Intravenous ketamine for subacute treatment of refractory chronic migraine: a case series. J Headache Pain. 2016;17(1)106-110.
