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A case of chronic migraine headaches treated with intrathecal ziconotide

A case of chronic migraine headaches treated with intrathecal ziconotide A case of chronic migraine headaches treated with intrathecal ziconotide
A case of chronic migraine headaches treated with intrathecal ziconotide A case of chronic migraine headaches treated with intrathecal ziconotide

A 59-year-old female presented to a clinic complaining of severe pain in her legs and unbearable unilateral headache (affecting right side) associated with extreme sensitivity to light and sound and altered vision. She experienced 22 migraine attacks in a month for over a decade. She had an intrathecal pump placed for spasticity caused due to multiple sclerosis and also had a history of polyneuropathy. She had tried a variety of pain-relieving medications, including ibuprofen and other NSAIDs, but there was no improvement in pain.

 

The most likely diagnosis of this presentation is

  • Unexplained Headache
  • Migraine headache
  • Multiple sclerosis
  • Trigeminal neuralgia


Migraine refers to a recurrent headache (mostly unilateral or sometimes bilateral) often accompanied by nausea, vomiting, photophobia, phonophobia, and hyperosmia. Migraine may take place with or without aura. Aura symptoms generally include altered vision or focal motor seizures. Migraine is a prevalent disorder affecting almost 12% of the western population, especially women of 22 and 55 years. Though it may affect anyone, it is more common in females, accounting to 3-10% of the female population. In male population, the prevalence is around 1–4 %. The higher prevalence in females may be attributed to menarche, menstruation, pregnancy, and menopause as use of oral contraceptives and of hormone replacement treatment (HRT). Severe migraine is ranked in the highest disability class by the WHO. Migraine may affect wellbeing and overall quality of life. It is estimated that approximately 30% of migraine affected individuals either remain undiagnosed/misdiagnosed or inadequately treated. 

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Key take away

Patient presented with severe migraine headaches had complete resolution of migraine headaches with low-dose intrathecal ziconotide.

Medical history

The patient had a history of peripheral polyneuropathy and pain affecting the legs as well as severe, chronic migraine headache.

Examination & lab investigations

Since the patient was already diagnosed with chronic migraine, assessments during this visit included evaluation of personal and medical history, extensive work up to look for other forms of headaches (including blood tests, CT scan, and lumbar puncture) blood pressure measurements and general physical examinations. 

Further, extensive neurological exam indicated changes in far-flung neural networks within the central nervous systems (CNS), including the cerebral cortex, brainstem, hypothalamus, and thalamus.

Management

The symptoms of spasticity were significantly improved with intrathecal baclofen. Therefore, a low-dose of ziconotide (1 µg/day) was introduced to relieve neuropathic pain in her legs for eight weeks. Her total daily intrathecal treatment consisted of baclofen (89.88 µg) and ziconotide (1.0068 µg). Additionally, a flex dosing parameter was started; she received 10.98 µg of baclofen and 0.1230 µg of ziconotide every four hours (6 doses/day). The flex doses were given for 2 minutes. The patient was not prescribed with any triptans or other agents after initiating on ziconotide approach.

As a result, a significant improvement in both neuropathic pain and complete resolution of migraine headaches was reported after eight weeks of treatment. She did not experience any migraine attack during this treatment duration.

Discussion

In the present case study, complete relief in chronic headache symptoms with features of migraine was observed with ziconotide treatment. Migraine remains an elusive and poorly understood disease, and the treatment approach is often categorized as preventive and abortive approaches. The precautionary approach involves a variety of medications, including antihypertensives, antidepressants, antiepileptics, Botox injection, and supplements, primarily to manage episodic migraine than chronic migraine. NSAIDs, ergotamine derivatives and triptans are the common abortive drugs.

 

Ziconotide is an intrathecal analgesic drug, often used as an essential alternative in the treatment of chronic intractable pain. The underlying mechanism of action for Ziconotide’s potent analgesia is associated with its ability to interrupt Calcium-dependent primary afferent transmission of pain signals in the spinal cord. According to study results by Klotz U., ziconotide was significantly effective than placebo in the treatment of chronic malignant and non-malignant pain. A low dose is advised for initial doses. In contrast, the gradual increase in dose helps to minimize the incidence and severity of adverse events associated with Ziconotide such as dizziness, nausea, confusion. Ziconotide offers and maintains a long-term efficacy and is not associated with tolerance issues, dependence or respiratory depression.

 

Previous evidence has confirmed the feasibility and usefulness of intrathecal ziconotide in the management of refractory chronic pain. According to Saulino M. et al., patients with neuropathic pain and spasticity could be effectively treated with the combination of intrathecal ziconotide and baclofen therapy. 

 

Although, there is a lack of data reporting treatment of migraine headaches with ziconotide, a case of trigeminal neuralgia improved with intrathecal ziconotide is evidenced. Therefore, this case represents the first case of migraine successfully treated with intrathecal ziconotide.

Learning

Ziconotide is a new alternative analgesic for the acute and long-term treatment of severe pain, especially in patients refractory to opioids and other traditional approaches.

References

    1. Di Lorenzo C,  Grieco S G, and Santorelli FM. Migraine headache: a review of the molecular genetics of a common disorder. J Headache Pain. 2012 Oct; 13(7): 571–580.
    2. Sacco S,  Ricci S,  Degan D, and  Carolei A.  Migraine in women: the role of hormones and their impact on vascular diseases. J Headache Pain. 2012 Apr; 13(3): 177–189.
    3. Hansen J M,  Lipton R B, Dodick D W. Migraine headache is present in the aura phase A prospective study. Neurology. 2012 Nov 13; 79(20): 2044–2049.
    4. Narain S,  Al-Khoury L, and  Chang E. Resolution of chronic migraine headaches with intrathecal ziconotide: a case report. J Pain Res. 2015; 8: 603–606.
    5. and baclofen provide pain relief in seven patients with neuropathic pain and spasticity: case reports. Eur J Phys Rehabil Med. 2009 Mar;45(1):61-7.
    6. Saulino M, Burton AW, Danyo DA, et al. Intrathecal ziconotide Sacco S,  Ricci S,  Degan D, and  Carolei A.  Migraine in women: the role of hormones and their impact on vascular diseases. J Headache Pain. 2012 Apr; 13(3): 177–189.

Source:

J Pain Res. 2015; 8: 603–606.

Article:

Resolution of chronic migraine headaches with intrathecal ziconotide: a case report

Authors:

Sachin Narain et al.

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