Marshall C. Freeman, MD, FAHS
Headache Medicine is a developing specialty. Headache Wellness Center is actively involved in headache research. Over the past few years, we have participated in research leading to new and ground-breaking treatments. The reader may be interested to learn about some of the highlights (great and small) of Headache Medicine published in the headache literature over the past year.
Starting with the most important headache-treatment advance in the past twenty-five years, the newest medications for migraine prevention have been developed and are effective. Calcitonin Gene-Related Peptide (CGRP)-modulating medications are designed to reduce the inflammation and activation involved in a migraine. The medications can be self-injected once or twice per month or may be administered intravenously every three months in order to reduce the total frequency of migraine events. A number of companies have worked on this type of medication, including Alder, Amgen, Lilly, and Teva Pharmaceuticals. The hope is that these non-oral medications will be more effective than current oral medications and possibly replace daily pills, thus improving compliance with treatment. Alternatively, these medications may be used as an add-on treatment for those individuals with highly resistant migraines who may need more than one therapy for care.
The association between migraine and abuse has been recognized. Different types of abuse include emotional, physical, and sexual. A study from the Department of Neurology at the University of Toledo examined the relationship between onset of abuse and migraine. The investigators evaluated data from the National Longitudinal Study of Adolescent Health (Add Health), which is a sample of American adolescents (grades 7-12) from 132 schools. Within the total sample, 14% reported migraine, 15% reported depression, and 12% reported anxiety disorder. Looking at just the migraine group, 35% reported depression and 25% reported anxiety disorder, a significantly higher number over the total group numbers. Approximately 61% of migraineurs reported abuse compared to 49% of non-migraine sufferers, both populations with surprisingly high frequencies. The final analysis determined that those individuals who reported childhood abuse were 1.7 times more likely of having migraine. Each type of abuse was associated with a higher likelihood of migraine, but the relationship to emotional abuse seemed greatest.
Ketamine is a chemical principally used as an anesthetic. It first became widely used during the 1970s. Structurally ketamine is a derivative of phencyclidine or PCP, better known as “angel dust.” While PCP is no longer available for medical use due to its withdrawal side effects of hallucinations and delirium, ketamine remains available. Colorful street names for ketamine include “K,” “Special K,” “Kit Kat,” and “Cat Valium.” Ketamine use may reduce pain, cause sedation, and create trance-like states. A number of centers are exploring the use of sub-anesthetic ketamine use for the treatment of chronic migraine, fibromyalgia, and depression. A study from the Thomas Jefferson University explored “Ketamine Infusions for Treatment-Refractory Headache.” A total of 77 patients with a diagnosis of chronic migraine or new daily persistent headache (NDPH) between 2006 and 2014 were admitted to the hospital and treated with intravenous ketamine (up to 1 mg/kg/hour) continuously for up to 5 days. A total of 55 subjects (71.4%) reported a partial pain reduction by the completion of the infusion. Fifteen of those subjects (27.3%) maintained an improvement at the time of their next scheduled revisit; however, according to the authors those 15 subjects reported a progression of their headache pain by the time of the revisit. It was, therefore, the opinion of the authors to consider ketamine infusions for acute management of refractive headaches only and that further research into the intervention should be performed.
Are you a scuba diver? In the article, “Migraine with Neurological Features in a Scuba Diver with a Patent Foramen Ovale,”, the authors review data suggesting that decompression illness from scuba diving occurs more frequently in individuals who have a patent foramen ovale (a defect of the heart), which is seen more often in those patients who have migraine with aura. In fact, certain international diving organizations already recommend special cardiac screening for divers who have migraine with aura. If a patent foramen ovale is identified, then the diver might consider surgical closure of the defect, or modification of the diving activity.
Finally, a case report summary submitted from a neurologist in Brazil. Do animals suffer from migraine? Dr. Silva-Neto describes a case from 2013 of a Cocker Spaniel with unusual vocalizations (suggesting pain) and frequent lip-smacking and swallowing (suggesting nausea) lasting up to 3 days in duration and occurring 1-2 times per month. After each event, the dog would remain quiet and listless for another 1-2 days, until returning to normal behavior and activity. All medical evaluations were normal. The dog was placed on topiramate, a migraine preventive medication, and the recorded episodes diminished to one event every 2-3 months. Is it migraine?
Marshall C. Freeman, MD, FAHS, FAAN is the director of Headache Wellness Center (HWC) in Greensboro, NC. He is a board-certified neurologist in Adult Neurology, Neuromuscular Medicine, and Electrodiagnostic Medicine. He is a Fellow of the American Headache Society and holds specialty certification in Headache Medicine by the United Council of Neurological Subspecialties. HWC is the oldest and longest continuously operating headache specialty practice in North Carolina, serving the headache population since 1990. HWC is actively accepting new adult and pediatric patients. Please contact our office if you are interested in our current migraine studies. Visit www.HeadacheWellnessCenter.com or call 336-574-8000.
