The patient can be kept in hospital overnight for observation, and then discharged if there are no further obvious medical injuries. The agency now reports that these agents are contraindicated in pregnant women for the prevention of migraine headaches.7 The β-blocker propranolol is often tried as initial prophylaxis therapy. Many people forget that the pharmacologic profile of DHE is predominantly that of a venoconstrictor, as well as a relatively mild arterial constrictor. A brain injury is damage that causes the destruction or deterioration of brain cells. Orlando, Florida. Cammarata D, Krusz JC. A cognitive disorder is when your brain does not work correctly after a traumatic brain injury (TBI). What are the risks of rehab after traumatic brain injury? It seems as if virtually every combination of IV medications at our disposal has been tried or given in our clinic at one time or another. 2. Krusz JC. Yet both groups required additional rescue treatment with analgesics (57%-79%) after initial treatment with an antiemetic.34 Another ED study compared the efficacy of IV MgSO4 with prochlorperazine in acute headache patients. Olesen J, Goadsby PJ, Ramadan NM, Tfelt-Hansen P, Welch KMA. I have used IV lidocaine, with pulse oximetry monitoring, in the clinic for many years for the treatment of migraine, headache, and pain flare-ups. Intravenous magnesium sulfate in the treatment of headaches. We will only contact you in connection with your enquiry and won’t pass your details to any third parties. I strongly suggest that advanced cardiovascular life support–trained staff and a crash cart with oxygen and medications are in the clinic treatment area. Raskin NH. Silberstein SD, Young WB, Mendizabal JE, Rothrock JF, Alam AS. In our study, we treated 79 patients with IV tramadol. This is based on a study of 202 migraine patients. PTSD was first officially recognized in the Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. June 2011: Abstract 15. Intravenous valproate sodium in the treatment of migraine headaches in the headache clinic. Triptans can be used in conjunction with antiemetics (metoclopramide [Reglan], ondansetron [Zofran], promethazine [Phenergan], etc), and perhaps anti-inflammatory compounds. Montreal, Canada: June 2000. May 2013: Abstract 378. Medication in other categories (so-called antipsychotic agents) have also been used to suppress migraines (eg, ziprasidone) and can be very useful in post-concussion headaches accompanied by irritability, mood instability, and sleep disorders.15. Washington, DC. Unger J, Cady RK, Farmer-Cady K. Understanding migraine: treatment options. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm350866.htm. Chronic pain sufferers are using our pain specialist directory to find pain specialists in your area. A traumatic brain injury can lead to many changes in a person’s life. Krusz JC, Daniel D, Cagle J. IV Levetiracetam efficacious for cluster headache. Sports concussion and associated post-traumatic headache. It caused speculation as to the role this receptor might play in migraines. I have listed all of the IV treatments to be described in the following sections in Table 3, which are based on my clinical experience. Krusz JC. Just as two people are not exactly alike, no two brain injuries are exactly alike. Fewer than 50% had successful resolution with ketamine.65 In this study the dose of ketamine was low, but more work needs to be done with this specific blocker of NMDA glutamate receptor subtypes. This can sometimes lead to brain damage, which can be temporary or permanent. More than 95% of our clinic patients fared exceedingly well as far as their headache and pain symptoms were concerned.16 We arbitrarily defined success as a greater than 50% reduction in the headache, based on a 0 out of 10 visual analog scale (VAS) from baseline. Lidocaine is an indiscriminate blocker of sodium (Na+) channels. Krusz JC, Belanger J. Saadah HA. Long-term use of steroids has its own side effect profile. If migraines are present >2 to 3 times per week, it may be wise to consider a suppressive or prophylactic medication (see next section). Krusz JC, Cagle J, Scott V. IV valproate for status migrainosus in the headache clinic. Krusz JC, Cammarata D, Cagle S. IV ketamine for treatment of refractory pain disorders in the clinic. Two studies found poorer outcome in the lidocaine-treated patients than with DHE, chlorpromazine treatment IV,57 or against placebo.58 The response to IV lidocaine was better in chronic daily headache in two retrospective studies.59,60 We have re-explored IV lidocaine for treatment of refractory migraines and have shown some promising data.61,62 However, this was an off-label use of lidocaine and, due to its ability to block neuropathic pain, it may play a roll in the treatment of refractory migraine post TBI. Sedation and cognitive side effects, such as confusion or memory problems, however, may limit the use of topiramate. 32nd Annual Scientific Meeting of the American Pain Society. A reformulated diclofenac potassium preparation (Cambia), with very rapid absorption kinetics, is also FDA indicated for mild to moderate migraine. Dr Silver offers invaluable insight into simple assessments of and treatment for fatigue that are commonly overlooked and explores other treatable symptoms arising from brain injury including poor cognition, sleep difficulties, dizziness and mood disturbance. Antidepressants 5. Access to the PPM Journal and newsletters is FREE for clinicians. Krusz JC. Memantine for treatment of cognitive deficits after traumatic brain injury. Oxcarbazepine as migraine prophylaxis. – Occupational Therapist Kate Meads gives an expert’s guide. Krusz JC. Off-label use of medication is perfectly legitimate as long as the clinician explains that to the patient. Vinson DR. Preventing further injury to the head or neck. 15th Congress of the International Headache Society. This might include anxiety, depression, bipolar-like symptoms, seizures, high blood pressure, irritability, poor sleep, and mood swings. Muscle spasm and pain as distinguished from migraines were rated by patients using a VAS every 15 minutes. Krusz JC, Nett RB. Intravenous valproate sodium in the treatment of daily headache. Many of the neuronal stabilizing agents include this mechanism of action. Droperidol treatment of status migrainosus and refractory migraine. DHE can be given IV or IM and has a 10- to 14-hour half-life. About 2 billion people worldwide have been treated for pain with this agent, which is a µ opioid receptor agonist, as well as weak presynaptic reuptake inhibition of norepinephrine and serotonin (like venlafaxine, duloxetine, or milnacipran). Of course, we make every effort to use one medication at a time and to carefully document the percentage of pain reduction of that single agent. Prophylaxis for chronic daily headache and chronic migraine with neuronal stabilizing agents. Sometimes, interesting results are stumbled upon serendipitously, as occurred in the case of the pre-anesthetic agent propofol. Practical Pain Management is a Remedy Health Media, LLC web property. At the end of treatment, migraines were absent in 24 patients.79. Intravenous lignocaine infusions for severe chronic daily headache. Headache is the most common and among the most prevalent persistent symptoms following mTBI. Time: 1:00 -­ 1:15pm. One study administered ketamine intranasally to migraine patients who had pronounced and disabling aura. P7C3-A20 treatment one year after TBI in mice repairs the blood–brain barrier, arrests chronic neurodegeneration, and restores cognition. OBJECTIVES To better establish the clinical features, natural history, clinical management, and rehabilitation implications of dysautonomia after traumatic brain injury, and to highlight difficulties with previous nomenclature. Since then, topiramate (Topamax) has been approved for migraine prophylaxis and one of its mechanisms of action is on GABA-A receptors. While head injuries are one of the most common causes of death and disability in the United States, many patients with head injuries are treated and released from the emergency department after receiving treatment. Another small study evaluated the same protocol in a headache clinic against IV ketorolac and found the DHE protocol to result in a greater degree of pain improvement (P=0.31) and better function clinically (P=0.057).42 Various IV protocols available for clinic use were subsequently summarized by the same author.43. Reutens DC, Fatovich DM, Stewart-Wynne EG, Prentice DA. Traumatic brain injury (TBI) is commonly defined as an insult to the brain from an external force that causes temporary or permanent impairment in functional, psychosocial, or physical abilities.1 It is a significant cause of morbidity and mortality, and the leading cause … American Academy of Pain Management Annual Meeting. Baclofen is a GABA-B receptor agonist, a unique mechanism of action. Join a support group. Friedman BW, Corbo J, Lipton RB, et al. The original IV DHE protocol to treat refractory migraine headaches was introduced in 1986 by Professor Raskin and it became the mainstay of inpatient and in-clinic treatments.40 Typically, DHE (1 mg) is given every 8 hours with IV metoclopramide 10 mg for 2 to 3 days. Soon thereafter, other open-label studies, including our own, began to show up in the literature48-50 documenting efficacy of valproate sodium IV in treating migraines. Migraine-specific abortive therapy centers on the triptan family of compounds. Cognitive impairment is common after TBI, with treatment limited by the heterogeneity of injuries. Memantine for migraine and tension-type headache prophylaxis. 1-4 Studies to date have documented that anywhere from 30-90% of individuals who sustain a mTBI develop post-traumatic headache. American Academy of Pain Management Annual Meeting. The specific pharmacologic effect of propofol, with sole effects on subtypes of the gamma-aminobutyric acid type A (GABA-A) receptor, is a unique mechanism of action. May 2013: Abstract 382. Krusz JC. Theses agents primarily decrease neural activity in trigeminovascular afferent nerves that are sending signals from dural nerve endings to the trigeminal nucleus caudalis in the brainstem. Acute migraine treatment with droperidol: a randomized, double-blind, placebo-controlled trial. Migraine headache: immunosuppressant therapy. Intravenous magnesium sulfate relieves cluster headaches in patients with low serum ionized magnesium levels. IV tramadol: very efficacious treatment for pain and headache in the outpatient clinic. July 1999. Mathew NT, Kailasam J, Meadors L, Chernyschev 0, Gentry P. Intravenous valproate sodium (Depacon) aborts migraine rapidly: a preliminary report. April 2009: Abstract 221. Blockade of this system has definite implications for reducing neuropathic pain disorders. Webinar recording: Stewarts Soundbites Episode 12 – Rental Properties after Serious Injury; Obstacle or Opportunity? Other authors have published results from their own clinics, showing that dexamethasone was indeed effective in their migraine and status migraine populations.38,39 This is not necessarily followed by an oral taper. Originally, it was noted serendipitously to help migraine headaches when it was being used for management of blood pressure and cardiac rhythm disorders. 47th Annual Scientific Meeting of the American Headache Society. Traumatic events that can result in PTSD fall into … 2,5 Interestingly, several researchers have reported that post-traumatic headache is more common after concussion/mTBI than after severe TBI. In the future, we will undoubtedly have more unique pharmacologic agents to treat post-TBI migraines more effectively. It’s not surprising that headache would be the most common physical symptom after a brain injury. In our search for additional IV agents to use in the clinic for intractable migraines, we turned to this compound and presented an initial open-label study in poster form.47 Our results showed an impressive reduction in migraine severity, both in this initial trial and in subsequent studies. Levetiracetam (Keppra) as prophylaxis for resistant headaches. Emergency treatment of intractable migraine. Stillman MJ, Zajac D, Rybicki LA. Traumatic brain injury is defined as a traumatically induced structural injury and/or physiological disruption of brain function as a result of an external force that is indicated by new or worsening of at least 1 of the following clinical signs, immediately after the event: Brain injuries can lead to a wide variety of symptoms and effects, and each case is unique. Thus, keeping doses quite low (around 2 mg total) can be very effective and I have quite a number of patients who use IM droperidol at home as rescue medication for their migraines—either with migraine-specific therapy or to avoid a trip to the ED. Part 1 of this series described the biomechanics and pathophysiology of traumatic brain injuries, as well as their symptoms: post-concussion syndrome, post-traumatic headache, and migraine. TBI can be classified based on severity (ranging from mild traumatic brain injury [mTBI/concussion] to severe traumatic brain injury), mechanism (closed or penetrating head injury), or other features (e.g., occurring in a specific location or over a widespread area). Post-concussion syndrome (PCS), or post-concussive syndrome, refers to the lingering symptoms following a concussion or a mild traumatic brain injury (TBI).. Traumatic brain injury. Nociceptive pain, peripheral and central sensitization, windup, long-term potentiation, and neuroplasticity are concepts basic to the expression and maintenance of these disorders. The potentiation of narcotic analgesics with phenothiazines. It uses surgically implanted electrodes to send high-frequency signals to the thalamus, the structure in the brain that controls involuntary movements. Ginder S, Oatman B, Pollack M, A prospective study of IV magnesium and IV prochlorperazine in the treatment of headaches. This part of the article attempts to describe more aggressive and definitive treatments available in the outpatient headache clinic setting. Ensuring adequate oxygen flow to the brain 2. The results showed an average reduction in pain severity after treatment from 7.46 on the visual analogue scale (VAS) to 2.81 (P<.001).76. In this episode, Emma Lyons and Dr Silver discuss the origins of fatigue after traumatic brain injury as well as the potential treatable causes. Gallagher RM. The agent is usually well tolerated in the lower doses used for headaches; however, the FDA recently issued a warning that valproate sodium can cause decreased IQ scores in children whose mothers took the medication during pregnancy. Elvis Presley: Head Trauma, Autoimmunity, Pain, and Early Death, Traumatic Brain Injury: Treatment of Post-traumatic Headaches, Advances in Pharmacologic Pain Management of Juvenile Idiopathic Arthritis, Integrative Treatment Approaches for Juvenile Idiopathic Arthritis, How Changing Hydrocodone Scheduling Will Affect Pain Management, Editor's Memo: Interpreting Indications For Electromagnetic Therapy. Our newsletters are sent no more than once a month. New Orleans, Louisiana. Ziprasidone as prophylaxis for chronic daily headaches. Ketamine, an agent specifically active against NMDA-type glutamate receptors in subanesthetic doses, has been little studied thus far, but may have theoretical implications for preventing chronic migraines. For the person or their family, there are several effects and much to learn on the road to recovery. The total dose (subanesthetic) was only 120 mg, given slowly by IV push 20 mg at a time. Headache Update Annual Meeting. Krusz JC. Migraine-type headaches in children receiving chemotherapy and ondansetron. September 1996. This suggested that we were not only clinically efficient but, on a cost basis, an aggressive clinic treatment of headache was less expensive than treatment in the emergency department (ED) as well. There is substantial literature on the use of IV magnesium for migraines and cluster headaches.19-22 The original studies by Mauskop and colleagues studied ion-sensitive Mg++ electrodes to measure ionized magnesium, a technique not commonly available. Krusz JC, Scott VB, and Belanger J. A third study, however, found that valproate sodium was significantly less useful than prochlorperazine (Compazine) in the ED for headache pain (9 mm vs 64.5 mm, respectively) and nausea symptoms (35.5 mm vs 2 mm, P<0.001).52 A different study treated mostly chronic daily headaches, chronic TTH, and unclassifiable chronic headaches (67%), with just over 30% episodic migraines. Relieving pressure in the skull Medications These medications may include, but are not limited to: 1. Please add updates@practicalpainmanagement.com to your address book to ensure delivery. As swelling decreases and blood flow and brain chemistry improve, brain function usually improves. Sodium valproate has a prophylactic effect in migraine without aura. Read our Privacy and Data Protection page for more information. We reported an 88% reduction in severity of migraine, based on patient-rated VAS, in the IV valproate sodium group. Miami, Florida: April 2005. The starting dose is 0.625 mg of IM droperidol, repeated after 20 to 30 minutes, and once again if needed. This condition is … Some of the triptans are available in faster delivery systems like injectable and nasal spray. report that dopaminergic imaging can be used t We use cookies to enhance your experience on our website.By continuing to use our website, you are agreeing to our use of cookies. Post-traumatic stress disorder (PTSD) can develop after a very stressful, frightening or distressing event, or after a prolonged traumatic experience. Renew Your Subscription and List Your Practice for Free! Valproate sodium has been a popular migraine preventive. A moderate head injury is defined as loss of consciousness for between 15 minutes and six hours, or a period of post-traumatic amnesia of up to 24 hours. Klapper JA, Stanton JS. Berlin, Germany. Robbins L, Conidi FX. A TBI often damages the front part of your brain, which is the part of the brain used for thinking and memory. They should be used for disabling migraines that are moderate to severe in intensity. Register now and get your name in front of these patients! 3. Post-traumatic headaches, often considered to be extremely difficult to treat, are actually easier to treat than most people realize if you pay attention to the parameters outlined in this article. A severe head injury can result in pressure being placed on the brain because of bleeding, blood clots or a build-up of fluid. Intravenous propofol: unique effectiveness in treating intractable migraine headaches. The spectrum of abortive medications is covered extremely well in some of the comprehensive textbooks about headaches and migraines, including the role of opioids.4-6 A selective list of FDA-approved agents are highlighted in Table 1. Semenchuk MR, Davis B. Efficacy of sustained-release bupropion in neuropathic pain: an open-label study. American Headache Society 49th Annual Meeting. Bell R, Montoya D, Shuaib A, Lee MA. Krusz JC, Robbins L. Traumatic brain injury. Most often these have the characteristics of migraines, migrainous headaches, and mixed tension-type headaches (TTH) and migraines, as was discussed in Part 1 of this series.1 There have been a number of recent articles in medical journals that have renewed the debate about TBI, including an articl… Managing Post-Traumatic Headaches After Traumatic Brain Injury - VHL HealthSheet #41359_VA traumatic brain injury (TBI) is a sudden jolt to your head that changes the way your brain works. You can change your cookie settings at any time. CSF glutamate levels in chronic migraine. Krusz JC, Scott V, Belanger J. Besides these FDA-approved medications, virtually all of the anticonvulsants (we much prefer the phrase "neuronal stabilizing agents") have been tried in small trials, which are usually open label in nature. Common neurocellular and neurotransmitter pathways may explain the clinical expression of both neuropathic pain and migraine and associated hyperalgesia and central sensitization.63 On the treatment side of things, why is it that medications with completely different structures but similar mechanisms of action (propofol and topiramate, each of which act on GABA-A receptors) both reduce migraines, other headaches, and pain? Therefore, all my information is anecdotal and I rarely use it alone but, instead, often use it after other agents. Our preference is for the prescription of the more potent antiemetics, including ondansetron or metoclopramide. Traumatic Brain Injury (TBI) is a disruption in the normal function of the brain that can be caused by a blow, bump or jolt to the head, the head suddenly and violently hitting an object or when an object pierces the skull and enters brain tissue. A cohort of 77 patients were treated and the results were dramatic.55 Propofol was the most effective IV agent that we had ever employed, with a 95% success rate in reducing ongoing migraine headaches. 27th Annual Scientific Meeting, American Pain Society. 8th World Congress. Accessed May 6, 2013. May 2013: Abstract 381. Therefore the best advice when treating mental symptoms in a patient with a brain injury is to be symptom-specific and to use the same drug you would for someone without a brain injury. I have had about 200 patients over the last 15 years for whom the addition of methocarbamol (range: 300-500 mg) was a positive element in their overall headache relief. Objective: To investigate clinical characteristics and treatment patterns in persistent post-traumatic headache attributed to mild traumatic brain injury. This promises to be a fascinating 15 minute bitesize session for all involved in working with those who have sustained brain injury. Krusz JC, Cagle J, Daniel D. Intravenous levetiracetam for acute intractable migraines. Philadelphia, Pennsylvania: June 2005. METHODS Retrospective file review on 35 patients with dysautonomia and 35 sex and Glasgow coma scale score matched controls. Helsinki, Finland. Source: Our health information content is based on research evidence whenever available and represents the consensus of expert opinion of the TBI Model System directors. Treatment patterns of isolated benign headache in US emergency departments. Considering the evidence that excitatory amino acids like glutamate are the "bad guys" in promoting nociception in general—and hyperalgesia and possibly allodynia—it is not surprising that agents, which antagonize this system might have utility in reducing pain and headache symptoms. 64th Annual Meeting of the American Academy of Neurology. Therefore, approach to neurological rehabilitation and physiotherapy post-traumatic brain injury should observe neuroplasticity, motor learning, and motor control principles as well as the patient-centred approach with an individual’s goals settingand choice of treatment procedures. What is a cognitive disorder after a traumatic brain injury? Some of the most common methods include: Epworth Sleepiness Scale. Krusz JC. Dr Silver qualified in medicine in 1989 and trained to registrar level in general medicine prior to specialising in neurology. Consultant Neurologist Dr Nicholas Silver gives an insight into treatment for fatigue, cognition, sleep, dizziness and mood disturbance. Krusz JC, Cagle J. Efficacy of IV lidocaine to treat pain and headache flareups in the outpatient clinic. Cost effectiveness of clinic treatment of headaches and pain. This is a cost- and time-effective mode of treating intractable pain and headaches. Cammarata D, Krusz JC. Krusz JC, Daniel D, Cagle J. IV tramadol for treating refractory migraines. IV baclofen: treatment for refractory migraines and daily headaches C0-morbid with muscle spasm in the outpatient clinic. This month, our author tackles treatment of TBI headaches. Formal trials of IV lidocaine to treat acute migraine headache were published some time ago. JC Krusz, J Cagle, D Daniel, VB Scott-Krusz. Therefore, we have a compounding pharmacy make up a sterile, neutral pH solution for use in the headache and pain clinic. Abortive migraine therapy in the office with dexamethasone and prochlorperazine. Rozen TD. Edwards KR, Norton J, Behnke M. Comparison of intravenous valproate versus intramuscular dihydroergotamine and metoclopramide for acute treatment of migraine headache. In the author's practice, we successfully have used these, as well as droperidol intravenously (IV) in the clinic (in small doses). Stop football…save brains: a point counterpoint discussion. Baclofen IV in the clinic: effective treatment for muscle spasm pain and migraines. Krusz JC, Longmire DR. Tramadol in the treatment of headaches. We have used this agent routinely in the clinic as a mild sedative prior to epidural steroid and facet nerve blocks in a conscious sedation manner. Don't drive under the influence of alcohol or drugs, including prescription medications that can impair the ability to drive. Helmets. Controlling blood pressure 3. JC Krusz, J Cagle. Stewarts Soundbites Episode 13 : Distinguishing treatable symptoms after Traumatic Brain Injury. We undertook a formal open-label study in the headache clinic to treat refractory migraines unresponsive to usual abortive approaches. Coronado, McGuire, Faul, Sugerman, Pearson. The rise in popularity of e-scooters – what is the legal position in the UK? Jones J, Pack S, Chun E. Intramuscular prochlorperazine versus metoclopramide as single-agent therapy for the treatment of acute migraine headache. More data are available for the treatment of cluster headaches, status migrainosus, or analgesic rebound headaches.37 We frequently use dexamethasone (2-4 mg every 8-12 hours, as needed) for severe, refractory migraines along with IV MgSO4. If you require assistance from our team, please contact us or alternatively request a call back from one of our lawyers by submitting this form. Nicolodi M, Sicuteri F. Exploration of NMDA receptors in migraine: therapeutic and theoretic implications. Klapper JA. Often, the response is short-lived (12-48 h), which buys time for other treatments to be put in place. Dr Silver treats occipital nerve blocks for headache disorders, multiple cranial nerve blocks for headache disorders, cranial botulinum toxin (Botox) treatment for migraine and headache treatment, non-invasive stimulation (vagal nerve stimulation (gammaCore), trigeminal nerve stimulation (cefaly) and transcranial magnetic stimulation (eNeura) for the non-drug management of headache disorders and facial pain. In addition, magnesium augments serotonin, which may be a direct means of blocking migraines. A number of strategies can help a person with traumatic brain injury cope with complications that affect everyday activities, communication and interpersonal relationships. Aura in some patients with familial hemiplegic migraine can be stopped by intranasal ketamine. The study found that IV metoclopramide 20 mg was more effective than sumatriptan 6 mg subcutaneously at reducing pain intensity scores (reduction of 7.2 vs 6.2, respectively) and pain-free rates (59% vs 35%, respectively).26. Krusz JC, Cagle J, Cammarata D. IV ketamine: effective therapy in the clinic for refractory migraines. New Orleans, Louisiana. Tampa, Florida. Ketamine in an outpatient setting: effective treatment for neuropathic pain syndromes. Methods: A total of 100 individuals with persistent post-traumatic headache attributed to mild traumatic brain injury were enrolled between July 2018 and June 2019. Multiple Sleep Latency Test. Krusz JC, Belanger J. We always have a patient acknowledge this for any treatment, oral or IV, and document this in their chart and on paper. The Brain Injury Network (BIN), a brain injury survivor advocacy organization, recommends the emphasis of a traumatic brain injury (TBI) classification entitled Post TBI Syndrome. A small child should always sit in the back seat of a car secured in a child safety seat or booster seat that is appropriate for his or her size and weight. The Pain Clinic, Tenerife, Canary Islands. As we have used IV ketamine in the clinic for more than 12 years, we have presented our data for IV ketamine for treating refractory headaches and pain several times.67,68 This is an ongoing study, which includes post-TBI migraines and headaches (with and without pain) and may be the largest database for migraine, cluster, chronic daily headache, and rare subtypes like paroxysmal hemicrania, hemicrania continua, and trigeminal neuralgia with migraines.69,70. Additional surgery may include: 1. When we think of preventative therapy, it is wise to think about co-morbid post-concussion symptoms. When TBI migraines become disabling to one's lifestyle and occur more frequently than 3 times per week despite successful treatment with triptans or other migraine-specific therapies, it may be time to think about suppressive or prophylactic therapy. The injured person's eyes may remain closed, and the person may not show signs of awareness. Krusz JC, Scott VB, Belanger J. IV Droperidol as a treatment for acute migraine headache. The author has used venlafaxine (Effexor), duloxetine (Cymbalta), and milnacipran (Savella) off-label in his clinical practice. He is also involved in treatment trials for idiopathic intracranial hypertension. There are so many different combinations of pain presentations (eg, refractory post-TBI migraines/headaches with pain and with nausea, or accompanying muscle spasms, burning). Mauskop A, Altura BT, Cracco RQ, Altura BM. I know of no published studies looking at this medication in this setting. Part 3 of the series will discuss evaluation, treatment, and rehabilitation. Depending on the severity of injury, a family caregiver or friend may need to help implement the following approaches: 1. There is a growing body of evidence that a blockade of central dopamine receptor systems can enhance anti-nociception or the pain-relieving analgesic properties of opioids.27-29 One study of neuropathic pain suggested that bupropion might decrease neuropathic pain via an effect on presynaptic reuptake of dopamine.30 These properties might explain the ability of dopamine blockers, like metoclopramide or droperidol, to reduce migraine headaches—an effect we and others have noted in the clinic setting in the treatment of migraines. Rehab after a TBI is not likely to cause problems. September 1998. It is important to note that the author uses this preparation only in extremely refractory cases and very infrequently. 9th European Federation of Neurological Societies Annual Meeting. It can be given alone, or combined with either antiemetics or IV corticosteroids. He explains whether it is possible to distinguish between the pervasive and chronic symptoms compared to those which may be addressed by assessment and treatment. In severe cases, a doctor might recommend surgical interventions to treat tremors after brain injury. Subscribe – In order to receive our news straight to your inbox, subscribe here. Jensen R, Brinck T, Olesen J. Krusz JC. According to Seifert, there are approximately 3.8 million sports-related concussions occurring each year, providing unique treatment challenges for medical personnel.3 The presence of new onset or persistent headache following an injury often complicates return-to-play decisions. The manufacturer subsequently released an IV preparation for commercial use to treat only seizures, but our data preceded that formulation by several years. Intravenous magnesium sulfate rapidly alleviates headaches of various types. BACKGROUND: Headache is among the most common persistent symptoms after mild traumatic brain injury (mTBI). Repetitive intravenous dihydroergotamine as therapy for intractable migraine. The author's clinic compiled a track record in treating refractory headache and pain patients using IV medication therapy. The agent has been used successfully in the clinical setting as an adjunctive medication for intractable vomiting associated with prolonged migraines (dosage: 2-4 mg IV). Clinical data with the oral form of this neuronal stabilizing agent were the first available anywhere in the treatment of refractory migraine headaches,71 and this agent has a unique mechanism of action that effectively blocks high-voltage calcium channels—another major activity of many neuronal stabilizing agents. Emergency Treatment for TBI Emergency care may include: 1. One of the initial studies using IV droperidol used quite high doses (mean 16.6 mg) and reported nearly all of their patients being sedated and more than 50% having extrapyramidal symptoms 24 hours after treatment.31 We repeated the study in our clinic using from one fifth to one quarter of the dose of IV droperidol with only 3% side effects and well over 50% success rate in reducing or eliminating refractory migraines.32 A double-blind trial of IM droperidol,33 again using high doses of the medication, showed efficacy; the placebo response rate was 57% vs 84% for droperidol. In my opinion, the ideal headache clinic would offer a large number of IV services and be staffed by nurses trained in IV therapy and monitoring with pulse oximetry. A search of the literature surprisingly revealed very little data to support its use in the treatment of acute or refractory migraines. Nausea should always be treated alongside the migraine. Other agents in this large group were also studied for migraines, chronic daily headaches, and neuropathic pain by the same author.11 Unfortunately, in the vast majority of these studies the industry chose not to study the medication formally in a double-blind, placebo-controlled fashion. New Orleans, Louisiana. Anticonvulsants 4. The IV preparation of tramadol turned out to be very efficacious, very well tolerated, rapidly treated refractory migraines and mixed headaches, and gave me another tool to use in the clinic when other agents failed.75 Our most recent accumulated data were presented this year. Krusz, JC. For example, the author published the first data on migraine and neuropathic pain management treated with oxcarbazepine, levetiracetam, and zonisamide8-10 soon after they were officially released as seizure medications. Anti-anxiety medications 2. FDA warns pregnant women to not use certain migraine prevention medicines. May 2013. Anticoagulants 3. Intravenous lignocaine (lidocaine) infusion for the treatment of chronic daily headache with substantial medication overuse. Cluster headache flare-ups and pain flare-ups like trigeminal neuralgia and CRPS have also been treated in the clinic.72,73 This is a powerful, non-toxic form of treatment for many difficult pain and headache flare-ups. Khan RB. I had originally published data with the oral form of the medication in treating headaches74 and was impressed by its ability to treat chronic headaches and migraines. Letters to the Editor: Testosterone, Ultra-high Dose Opioids. A series of bitesize webcasts designed to deliver concise and interesting updates, conversations and presentations on a range of topics, brought to you by our specialist lawyers and featuring some special guest speakers – Find out more. The principles of drug treatment in somebody with a brain injury are outlined in Table 2. As you can imagine, agents that have worked successfully, perhaps many times before, might not work in the next particular situation and so we always have a "game plan" for the next agent. Nicolodi M, Sicuteri F. Negative modulators of excitatory amino acids in episodic and chronic migraine: preventing and reverting chronic migraine. Potentiation of opioid analgesia in dopamine. American Academy of Neurology Annual Meeting. April 2012: Abstract 3780. Richter PA, Burk MP. Post-TBI migraines, when accompanied by cognitive difficulties, have been shown to respond to the treatment memantine (Namenda), officially on the market only for management of dementia.12,13 However, many studies, primarily from Europe, have used this agent for various pain conditions off label, and we have used it as an agent to help with cognition after TBI.14, Antidepressants, particularly the serotonin-norepinephrine reuptake inhibitors, can help depression and anxiety, but they can also reduce pain and migraines post-TBI. Triptans act specifically on serotonin (5HT)-1B and 1D receptors. Increased attention to traumatic brain injury (TBI) has raised renewed interest in one of its consequencespost-traumatic headaches (PTH). A poster described increased cerebrospinal fluid glutamate levels in chronic migraineurs compared to non-migraine controls.66 Patients with migraines and fibromyalgia had higher levels than patients without chronic pain. Currently available treatments have limited efficacy. Once again, anxiety, akathisia, and somnolence were rated as severe in 30% of patients, presumably due to the high doses employed. Very few of the patients had to be retreated. Dr Silver provides a general inpatient and outpatient neurology service for a full range of neurological disorders (including epilepsy, blackouts, MS, neuropathy, sleep disorders, dementia, stroke, etc). IV baclofen for treating migraines accompanied by severe muscle spasm in an outpatient setting. This term would be used in an all-inclusive fashion and under its umbrella all medical, psychological and other diagnoses from post-tbi would be included. Always wear a seat belt in a motor vehicle. Flores JA, El Banoua F, Galan-Rodriguez B, Fernandez-Espejo E. Opiate anti-nociception is attenuated following lesion of large dopamine neurons of the periaqueductal grey: critical role for D1 (not D2) dopamine receptors. Our study included 85 intractable migraineurs. The paradigm is to treat very slowly, so as to saturate the Na+ channels and obtain the best possible blockade. Before triptans, the gold standard for treating intractable migraines was DHE, a compound similar to, but pharmacologically very different from, ergotamine. Memantine: novel mechanism for migraine and headache prophylaxis. Mauskop A, Altura BM. 56Krusz JC. The bottom line on preventative therapy for post-TBI headaches and migraines is to look for comorbidities that are present along with the headaches and to treat with an agent that can reduce the migraine frequency and severity and the comorbid clinical state. This is based on the notion that the use of both agents was somehow synergistic. Ondansetron, a 5-hydroxytriptamine type 3 receptor antagonist, is a very powerful antiemetic often used in the management of chemotherapy-induced nausea and vomiting. You can find further information regarding our expertise, experience and team on our Personal Injury page. August 2007. Animal experiments seemed to support this idea, but human studies are not at all conclusive on this point.24 I've looked for evidence of this, but it is almost non-existent; nausea is a prominent symptom accompanying headache. A traumatic brain injury (TBI), also known as an intracranial injury, is an injury to the brain caused by an external force. In addition, Botox is currently the only medication approved for prophylactic treatment of chronic migraine (Table 2). The fields of pain and headache management use common terminologies to describe these processes. Athens, Greece: September 2005. Magnesium has primary effects as a physiologic antagonist to calcium. Both agents are compatible in the same IV bag (unpublished observations). In many ways, IV magnesium sulfate (MgSO4) is sort of an "opening shot" for intractable headaches, both TBI migraines and not. He is involved in a number of national and international treatment trials in the field of headache and lead the headache research team at the Walton Centre. In the past, promethazine was the most frequently used antiemetic.25 However, our preference is to use either ondansetron or metoclopramide, both IV and intramuscular (IM), as a firstline antiemetic in the clinic. Hopewell CA, Krusz JC, Thomson JA. They are indicated for moderate to severe migraines, but early intervention in the migraine process is always desirable. Alcohol and drug use. King MA, Bradshaw S, Chang AH, Pintar JE, Pasternak GW. Glutamate, with its subtypes of receptor families, will be an active area of research and, hopefully, treatment. Compounds that block the NMDA sub-family of glutamate receptors either have low potency (dextromethorphan or memantine) or they have higher potency and a narrow therapeutic index (ketamine).64. Our initial data with migraines77 have since grown in numbers and types of migraines treated78,79 and these include post-TBI migraines with severe muscle spasms. Multiple types of headaches, including migraines, migrainous headaches, TTH, and cluster headaches responded to IV magnesium therapy.19 The headache sufferers with the best and longest response to this treatment also had the lowest ionized Mg++ levels, both for migraines as well as for cluster headaches.20 One study has summarized clinical data with IV MgSO4 using doses of 0.5 to 1 g.23 In general, the author uses higher doses than that, and typically uses 2.5 to 3 g.21,22, Antiemetics have been used along with acute opioid therapy for headaches and for pain treatment. A traumatic brain injury (TBI) is an injury that has occurred as a result of trauma to the head. Headaches and migraines that occur after a TBI can be treated in any number of ways by healthcare practitioners. While every injury is different, there are two main types of brain injury: traumatic brain injury (TBI) and acquired brain injury (ABI). Dr Silver is employed by the Walton Centre for neurology and neurosurgery where he runs the Headache Service, investigating and treating severe and refractory headache disorders.  His research interests include non-headache manifestations of migraine and other headache disorders and non-invasive neuro-stimulation and injection therapies for the treatment of headache disorders. Deep brain stimulation (DBS) is the most effective surgical treatment for tremors. Indeed, one small study involving 6 children described the development of severe daily migraine-like headaches during cancer treatment.36 All patients had received daily doses of ondansetron and had a personal or family history of migraines, which may have placed them at risk of developing ondansetron-associated migraine-type headaches. May 1998. Intravenous sodium valproate versus prochlorperazine for the emergency department treatment of acute migraine headaches: a prospective, randomized, double-blind study. Increased attention to traumatic brain injury (TBI) has raised renewed interest in one of its consequences—post-traumatic headaches (PTH). It was the first anticonvulsant molecule to be found useful in treating migraines in a prophylactic manner.44-46 An IV version of valproate sodium (Depacon) was developed and was used for treatment of seizures. You may have difficulty doing the same things that you did before the TBI. Role of magnesium in the pathogenesis and treatment of migraines. An IV form is available in Europe. Toronto, Canada. This small study (36 patients) found prochlorperazine to be statistically more effective at reducing pain than magnesium (90% vs 56%, respectively) with fewer side effects.35 One comment is that the dose of the MgSO4 was rather low at 1 g compared to our clinic IV doses of 2 g or greater. There is very little literature on the use of corticosteroids to treat migraines. Also, ergotamine is fraught with the possibility of rebound migraines and headaches (now termed "medication overuse headache"), whereas DHE does not have this property. The average dose was 423 mg (range: 250-1,100 mg), given over 95 minutes in our clinic. Follow these tips to reduce the risk of brain injury: 1. The first two medications were originally approved as anticonvulsants, but were found to be effective in managing migraine, chronic daily headaches, and cluster headaches. Specific Measurable Achievable Relevant Timed goals and patient’s involvement in goal setting allows the clear orientation of the rehabilitation process and en… Divalproex sodium (Depakote), as an enteric-coated preparation, was approved in 1994 for oral use in the prophylaxis of migraines in the United States. Although methocarbamol is an older muscle relaxant preparation with uncertain pharmacologic mechanism(s) of action, it is one of the very few available in an IV form and, for this reason, I sometimes use it in the clinic to treat migraines and other headaches—especially if accompanied by a lot of neck spasms. The second part of this series specifically addresses the treatment of PTH and does not claim to be comprehensive. Nevertheless, traditional ED treatment of headaches often uses a combination of opioids and antiemetics. Is intravenous lidocaine clinically effective in acute migraine? (DSM III) in 1980, and since that time a great deal of knowledge has accumulated about the characteristics of post-traumatic symptomatology, the epidemiology of PTSD, and assessment and treatment of individuals suffering from this disorder. They also have vasoconstrictive properties on blood vessels in this system, but the main effect is on neural firing. The future of aggressive pain and headache treatment of TBI-related headaches will reside in the sphere of the specialist's clinic. After researching the literature, we found no mention of this agent in the treatment of migraines. The pharmacologic treatment of acute migraine headaches. Williams DR, Stark RJ. An older ED study using IM prochlorperazine compared with metoclopramide found the former to be more reliable in reducing headache to the endpoint of the study (1 hour). Tramadol has been available in the United States for a number of years and has been used in Europe for more than 30 years. The authors noted that all the children responded to stopping the medication and starting treatment with standard anti-migraine therapy. Psychosis after traumatic brain injury (TBI) is a relatively uncommon condition that presents both clinical and conceptual challenges. Ketamine IV - for CRPS, TN/TMD and other neuropathic pain in the outpatient pain clinic. Krusz JC, Cagle J, Cammarata D. IV lidocaine: effective treatment for refractory migraines in the clinic. Klapper J. Divalproex sodium in migraine prophylaxis: a dose-controlled study. We have also anecdotally looked at small numbers of patients with painful disorders like trigeminal neuralgia, complex regional pain syndrome (CRPS), and other pain flare-ups and they seem to also respond to propofol (unpublished data). All of the same agents have also been shown, at least in open-label trials, to reduce migraines and other headaches.56. Seifert TD. This field is for validation purposes and should be left unchanged. FDA. Zonisamide in the treatment of headache disorders. When: Wednesday 2 December Intravenous valproate sodium in the treatment of refractory migraine headaches. 32nd Annual Scientific Meeting of the American Pain Society. 32nd Annual Scientific Meeting of the American Pain Society. A severe head injury can also cause other potentially serious complications, including: an infection after … What is vocational rehabilitation? I use it in an intrathecal sterile form (Gablofen) for epidural and facet blocks, but a commercially available IV form is not available in the United States. It has been estimated that the direct medical costs and indirect costs, such as lost productivity, of TBI totaled an estimated $76.5 billion in the United States in 2000.17,18. Ergotamine is a pure arterial vasoconstrictor. Schwartz TH, Karpitskiy VV, Sohn RS. 7th European Federation of Neurological Societies. Jenkins et al. 7th Congress European Federation of Neurological Societies. The key is to have a wide and varied repertoire of interventions to address each unique patient's pain presentation. Alternatively, please fill out this form with a summary of your enquiry and we'll get back to you. Comparison of dihydroergotamine with metoclopramide versus meperidine with promethazine in the treatment of acute migraine. Stimulants Rehabilitation T… Headaches after Traumatic Brain Injury was developed by Kathleen R. Bell, MD, Jeanne Hoffman, PhD, and Thomas Watanabe, MD, in collaboration with the Model Systems Knowledge Translation Center. If you require immediate assistance, please call one of the switchboard numbers on our Contact page. Atlanta, Georgia. Peres MFP, Zukerman E, Soares C, Augusto S, Alonso EO, Santos BFC, Faulhaber MHW. June 2007. Fourth International Congress on Neuropathic Pain. Comparisons of this protocol against "typical" treatment with meperidine (75 mg) and promethazine (25 mg) showed similar efficacy with significantly fewer side effects in the DHE/metoclopramide group,41 making it very useful for office-based treatment of migraines. Kaube H, Herzog J, Kaufer T, Dichgans M, Diener HC. American Pain Society's 27th Annual Scientific Meeting. More studies are in progress. Only four medications are FDA approved for this indication: topiramate (Topamax), valproate sodium, propranolol, and timolol (the last of which is available as an optic solution primarily, and is very hard to find in tablet form). It also blocks N-methyl-D-aspartic acid (NMDA)–type glutamate excitatory amino acid activity, and nitric oxide synthesis and release—all of which are factors in migraine pathophysiology or maintenance. Similarly, many agents that are approved for other uses have been used off-label for their abilities to help migraine patterns. Sodium valproate has a prophylaxis effect in migraine: a double-blind study vs placebo. May 2008. OBJECTIVE: To present a rationale for a novel behavioral treatment approach and a suppor Opioid Prescribing and Monitoring - Second Edition, Opioid Prescribing and Monitoring - First Edition. Most often these have the characteristics of migraines, migrainous headaches, and mixed tension-type headaches (TTH) and migraines, as was discussed in Part 1 of this series.1 There have been a number of recent articles in medical journals that have renewed the debate about TBI, including an article by Robbins and Conidi on sports-related injuries. Taylor BK, Joshi C, Uppal H. Stimulation of dopamine D2 receptors in the nucleus accumbens inhibits inflammatory pain. Tanen DA, MillerS, French T, Riffenburgh RH. Brussels, Belgium. Dr Silver is a pre-eminent Consultant Neurologist at The Walton Centre. Removing clotted blood 2. Compared with the treatments commonly available in the ED, the outpatient clinic can offer a wider variety of effective and definitive treatments and, thus, offer patients a maximum degree of success for control of their intractable pain symptoms. Thirteen of the 23 patients (57%) rated their migraines as 0 out of 10 in severity after treatment.54. Chicago, Illinois. Seat belts and airbags. Ketorolac versus DHE and metoclopramide in the treatment of migraine headaches. A trial of metoclopramide vs sumatriptan for the emergency department treatment of migraines. It was noted that some patients who had migraines at the time of their blocks would comment on eradication of the migraine before the block was performed, but after propofol was given. Brain injury may be caused by a direct blow to the head, but shaking may also cause damage. It consists of three parts: Acute treatment of post-TBI headaches using migraine-specific therapy, prophylactic therapy to suppress post-TBI headaches, and interventional treatments used in our outpatient headache clinic. Treatment of primary headache disorders with intravenous valproate: initial outpatient experience. Hering Rand Kuritsky A. Quite frankly, the "classic" migraine-specific abortive medications used for treatment of acute migraines and migrainous headaches—for example, dihydroergotamine (DHE-45) and triptans—are FDA indicated for moderate to severe migraines. Mauskop A, Altura BT, Cracco RQ, Altura BM. American Headache Society Annual Meeting. Hand PJ, Stark RJ. For this test, the patient takes a monitored nap during the … New Orleans, Louisiana. August 2003. The average dose of valproate was 720 mg, given IV over about 50 minutes (100-200 mg every 5-10 minutes).47 Another study investigated the use of valproate sodium (loading dose 15 mg/kg, followed by 5 mg/kg every 8 hours) in initial treatment of chronic daily headache, transformed migraine, and analgesic overuse headaches.51 The authors stated that headache improvement was reported by 80% of the patients treated with IV valproate sodium, especially if other agents were not effective. But there is always a risk that parts of treatment such as physical or occupational therapy might lead to new injuries or make existing symptoms or injuries worse if not done properly. A comparative trial of three agents in the treatment of acute migraine headache. Some headache and pain physicians think that neuropathic pain, chronic daily headaches, and migraines are, underneath it all, very similar in their biochemical underpinnings with respect to cellular mechanisms. I formulated a sterile IV preparation to treat headaches and pain. Repairing skull fractures 3. We developed an IV form of the same agent (with a compounding pharmacy) and evaluated levetiracetam IV in the treatment of refractory migraines. Treatment trials of psychotropics in brain-injured patients are lacking. Traumatic brain injury (TBI) is a leading cause of cognitive impairment that affects millions of people worldwide. Scherl ER, Wilson JF. Tampa, Florida. Proceedings of the National Academy of Sciences , … Muscle relaxants 6. Our study examined 63 patients with migraine, and muscle spasm and pain who were given 5 to 10 mg of IV baclofen at intervals of 10 to 15 minutes. Wang SJ, Silberstein SD, Young WB. In the first few weeks after a moderate to severe brain injury, swelling, bleeding or changes in brain chemistry often affect the function of healthy brain tissue. Traumatic brain injury (TBI) is a leading cause of cognitive impairment that affects millions of people worldwide. Can a Buprenorphine Transdermal System (Butrans) Be Used to Treat OUD? Lamotrigine for chronic neuropathic pain. Results showed that headache severity diminished from 7.9 on VAS to 3.2 (P<.001). More than half of the patients (57%) responded to valproate sodium treatment and the lower efficacy may be due to the nature of the chronic headache population treated in this study.53, We went over our initial study data and extracted 23 cases of bona fide status migrainosus from our initial published study sample treated with IV valproate sodium in the headache clinic.50 This very difficult-to-treat migraine population responded similarly as the refractory migraineurs, but needed a higher dose of valproate sodium (1,017 mg) and a longer treatment time (73 min vs 50 min).