Duren Michael Ready, MD FAHS Director, Headache Clinic Scott & White Healthcare DMReady@medicine.tamhsc.edu Disclosures & Shameless Plug Family Physician UCNS Certified in Headache Medicine Just one blind man at the elephant You can learn a lot at a Headache meeting 1
Why Migraine Why Should I Care TTH & Migraine 2 nd & 3 rd most prevalent disorder Migraine accounts 30% of global burden of disability & 50% of all Neuro disability medical 4 th leading cause of disability in women & 7 th overall Lancet 2012 Severe Migraine Is Ranked in the Highest Disability* Class by WHO Disabilit y Class Severity Weights *Assessments of disease severity determined by Global Burden of Disease researchers using the person trade-off 1.00 method, migraine, which includes quadriplegia judgments about the trade-off between quality and quantity of life. Spectrum ranges from 0 (perfect health) to 1 (death). WHO = World Health Organization. Menken M. Arch Neurol. 2000;57:418-420. MurrayCJ, Lopez AD. Lancet. 1997;349:1347-1352. Indicator Conditions 1 0.00-0.02 Vitiligo of face, weight for height less than 2 SDs 2 0.02-0.12 Watery diarrhea, severe sore throat, severe anemia 3 0.12-0.24 Radius fracture in a stiff cast, infertility, erectile dysfunction, rheumatoid arthritis, angina 4 0.24-0.36 Below-the-knee amputation, deafness 5 0.36-0.50 Rectovaginal fistula, mild mental retardation, Down syndrome 6 0.50-0.70 Unipolar major depression, blindness, paraplegia 7 0.70- Active psychosis, dementia, severe 2
Why should we do procedures? Even Teenagers 3
Procedures Lower Cervical Intramuscular Injections Occipital Nerve Block Sphenopalentine Ganglion Block Pericranial Bupivacaine Injections Lower Cervical Intramuscular Injections Headache 10/06 417 ED Pts / 1 yr 65% relief in 15m Repeat injection brought additional relief Worsened HA in 1% 4
Lower Cervical Intramuscular Injections 3mL bupivicane 0.5% 25g 1.5 / 27g 1.25 2-3cm lateral to the spinous processes between C6 & C7 AE /CI Vasovagal, Neck stiffness, usual injection risks Lower Cervical Intramuscular Injection 5
Lower Cervical Intramuscular Injection Occipital Nerve Block Local anesthetic (bupivicaine ).5% xylocaine 1% -- Duration of anesthesia doesn t correlate to duration of relief Steroid (triamcinolone 40mg/mL) evidence doesn t support general use 3mL total per side 25 or 27 gauge needle May place as a ridge of anesthesia, trigger points, or fixed. 6
Occipital Nerve Block Occipital Nerve Block AEs & CIs Prior hx of craniotomy over injection site AEs primarily related to steroid- fat atrophy, alopecia, pigment change Vagal response Happened to me X 3 in over 6000 blocks 7
Occipital Nerve Block Sphenopalentine Ganglion Block Over 100 years old Fell into disfavor Reemerged in 80s Patients may self administer Lidocaine May use cannula 8
Sphenopalentine Ganglion Block Sphenopalentine Ganglion Block 9
Robert Kaniecki, MD The Headache Center at the University of Pittsburgh Methods Protocol Administration of pericranial injections 12-week intervals 4 sets of injections over 48 weeks Fixed-dose (0.1 cc of 0.25% bupivacaine) Fixed-site (17 pericranial nerve injections each side) 10 injections: Greater and lesser occipital 5 injections: Auriculotemporal and zygomaticotemporal 2 injections: Supraorbital and supratrochlear 10
Methods Primary endpoint Mean change from baseline in the monthly frequency of headache days at week 48 Response defined as >50% reduction Secondary endpoints Mean change in monthly severe headache days Mean change in monthly acute medication days Mean change in HIT-6 disability scores 11
Results 218 subjects enrolled and treated Baseline Characteristics (n=218) Female (%) 87.1 Age (years) 40.4 History of migraine (years) 18.5 Headache days per 4 weeks 21.4 Severe headache days per 4 weeks 15.5 Acute treatment days per 4 weeks 18.3 HIT-6 score 66.2 Results 116 subjects (53.2%) met the primary endpoint with >50% reduction from baseline in monthly frequency of headache days at 48 weeks 77 subjects (35.3%) with response < 4 weeks 25 subjects (11.5%) with no response or lost to follow-up 12
Results Responder subgroup analysis (n=116) Mean monthly headache days from 22.8 to 9.0 Mean monthly severe headache days from 15.9 to 6.1 Mean monthly acute treatment days from 18.1 to 7.9 Mean HIT-6 score from 66.7 to 59.2 No clinical or demographic differences versus the nonresponder subgroup 13