Propofol: a new treatment strategy for refractory migraine headache

Comparing propofol with placebo for early resolution of acute migraine in adult emergency department patients: A double-blind randomised controlled trial

OBJECTIVE

To compare propofol with placebo in adult ED patients with acute migraine. Primary outcome was headache resolution by 1 h. Secondary outcome was reduction in headache severity by two or more points on a numerical rating scale.

METHODS

Double-blind randomised controlled clinical trial comparing propofol (10 mg/mL) with placebo (20% intralipid). Adults with acute migraine without aura were included. The study drug was administered as an initial dose of 4 mL followed by up to five doses of 2 mL, delivered 5 min apart. Pain scores were taken prior to each dose and further administration was ceased when either the pain score was zero or the maximum dosage reached (140 mg of propofol or 14 mL of 20% intralipid).

RESULTS

Of 40 recruited patients, 21 received propofol and 19 placebo. Headache resolution occurred for 5 (24%, 95% CI 13-57) and 6 (32%, 95% CI 13-57) patients, respectively, difference 8% (95% CI -20 to 36). Headache severity reduction by two or more numerical rating scale points was reported by 17 (81%, 95% CI 58-95) and 7 (37%, 95% CI 16-62) patients, respectively, difference 44% (95% CI 17-71).

CONCLUSIONS

Propofol was not superior to placebo for the primary outcome of early headache resolution. Superiority of propofol for the secondary outcome of headache severity reduction suggests that further research may be warranted.

The Multiple Functions of B Cells in Chronic HBV Infection

Chronic hepatitis B virus (HBV) infection is one of the main causes of liver diseases, of which the natural history and clinical outcomes are associated with the role of B cells. As humoral immune cells, B cells play a critical role in the process of anti-HBV antibody production. In addition, some studies have also characterized other B cell subsets involved in antigen presentation and regulating the immune response beyond antibody secretion. However, not all B cell subsets play a positive role in the immune response to chronic HBV infection, and various B cell subsets jointly mediate persistent HBV infection, tolerance, and liver damage. Thus, we further sought to elucidate the multiple functions of B cells to gain novel insight into the understanding of chronic hepatitis B (CHB) pathogenesis. We also reviewed the current immunotherapies targeting B cells to explore novel therapeutic interventions for the treatment of chronic HBV infection.

Propofol for Treatment of Acute Migraine in the Emergency Department: A Systematic Review

OBJECTIVES

Propofol has not been extensively studied as an acute migraine therapy; however, based on the limited evidence from outpatient and inpatient settings, propofol has been proposed as an option for patients who present to the emergency department (ED). The purpose of this review was to evaluate the existing literature regarding the safety and efficacy of propofol for acute migraine treatment in the ED.

METHODS

A systematic review of clinical studies of propofol treatment for acute migraine in the ED was performed using Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Trials were identified through PubMed, Google Scholar, clinical trial registries, research registries, and key journals through May 2019. A modified Jadad scoring system was used to assess the methodologic quality of the included randomized controlled trials, and the Newcastle-Ottawa Scale was used for the retrospective cohort study.

RESULTS

Nine studies, including five case reports or series, one retrospective cohort study, and three randomized controlled trials, consisting of 290 patients, were reviewed. All studies in adults reported propofol to be an effective therapy for migraine, but the strength of these results was limited by dosing variations, small sample sizes, and limited generalizability. Pediatric studies produced mixed results.

CONCLUSIONS

Propofol may be an effective rescue therapy for patients presenting to the ED for acute migraine, but its place in therapy based on the limited available evidence is unknown. The safety of propofol for migraine management in the ED has not been adequately examined.

Current Approach to Undifferentiated Headache Management in the Emergency Department

PURPOSE OF REVIEW

To discuss pharmacological interventions in the emergency department (ED) setting for the management of acute primary headache.

RECENT FINDINGS

Acute headache treatment in the ED has seen an expansion in terms of possible pharmacological interventions in recent years. After a thorough evaluation ruling out dangerous causes of headache, providers should take the patient's history, comorbidities, and prior therapy into consideration. Antidopaminergics have an established role in the management of acute, severe, headache with manageable side-effect profiles. However, recent studies suggest anesthetic and anti-epileptic drugs may play roles in headache treatment in the ED. Current literature also suggest steroids as a promising tool for emergency department clinicians combating the readmission of patients with recurrent headaches. Emergency medicine providers must be cognizant of these traditional and emerging therapies in order to optimize the care of headache patients.

Treatment of migraine attacks and prevention of migraine: Guidelines by the German Migraine and Headache Society and the German Society of Neurology

In collaboration with some of the leading headache centres in Germany, Switzerland and Austria, we have established new guidelines for the treatment of migraine attacks and the prevention of migraine. A thorough literature research of the last 10 years has been the basis of the current recommendations. At the beginning, we present therapeutic novelties, followed by a summary of all recommendations. After an introduction, we cover topics like drug therapy and practical experience, non-effective medication, migraine prevention, interventional methods, non-medicational and psychological methods for prevention and therapies without proof of efficacy.

The Effect of Propofol on Chronic Headaches in Patients Undergoing Endoscopy

Objective

This study determined acute and long-term effects of propofol administration in patients with severe headaches undergoing endoscopic procedures.

Background

Approximately 13% of the US population is affected by migraines or severe headaches. The effect of propofol on headaches more than a few days after the intervention has not been explored.

Methods

We employed a nonrandomized, prospective observational study that recruited patients with chronic headaches who received propofol from an outpatient endoscopy center for either upper or lower endoscopies. Patients completed the six-item Headache Impact Test (HIT-6) questionnaire prior to the procedure and 30 days after endoscopy. Additionally, the patients' response to propofol two days after endoscopy was assessed via phone.

Results

The age of the participants (n=31) ranged from 20 to 70 years. The mean HIT-6 composite scores were significantly lower (p < 0.05) 30 days after propofol administration when compared to baseline scores. Upon stratification, 23 patients indicated an improved condition, 7 a worsened outcome, and 1 showed no change. Furthermore, mean scores were significantly lower (p < 0.05) in three HIT-6 questions pertaining to the severity of pain, daily activity, and frequency of lying down. Finally, the mean pain score obtained was significantly lower (p < 0.05) two days after procedure.

Conclusions

The results of this suggest that propofol administration should be considered in treating chronic headaches. Double-blind studies are necessary to confirm these results.

Treatment of status migrainosus by general anesthesia: a case report

BACKGROUND AND OBJECTIVES

The status migrainosus is a complication of migraine characterized by severe headache for more than 72h that did not respond to treatment, with risk of stroke and suicide. Researches on treatment are directed to drugs that stimulate GABA receptors; propofol and isoflurane act on sub-GABAa receptors and theoretically could be interesting. The first has been the subject of research in severe migraine. Opioids are employed in pain, and its use in chronic headache is debatable, but these agents are employed in acute cases. The goal is to present a case of refractory status migrainosus in that we decided to break the pain cycle by general anesthesia.

CASE REPORT

Female patient, aged 50 years, with status migrainosus, in the last five days with visits to the emergency department, medicated parenterally with various agents without result. Without comorbidities, dehydrated, described her pain as "well over 10" in Visual Numeric Scale (VNS). After consulting the literature, and given the apparent severity of the condition, we opted for a general anesthesia: induction with fentanyl, propofol, and vecuronium and maintenance with isoflurane and propofol for two hours. Following the treatment, in the postanesthetic recuperation (PAR), the patient related her pain as VNS 3, and was released after five hours with VNS 2. Subsequently, her preventive treatment was resumed.

CONCLUSION

Status migrainosus is a rare disabling complication and anesthetics have been the subject of research in its treatment; the option for general anesthesia with agents that stimulate GABA receptors, propofol and isoflurane, in association with fentanyl, proved effective and should encourage new research.

Pediatric migraine: abortive management in the emergency department

Studies suggest that headache accounts for approximately 1% of pediatric emergency department (ED) visits. ED physicians must distinguish between primary headaches, such as a tension or migraine, and secondary headaches caused by systemic disease including neoplasm, infection, or intracranial hemorrhage. A recent study found that 40% of children presenting to the ED with headache were diagnosed with a primary headache, and 75% of these were migraine. Once the diagnosis of migraine has been made, the ED physician is faced with the challenge of determining appropriate abortive treatment. This review summarizes the most recent literature on pediatric migraine with an emphasis on diagnosis and abortive treatment in the ED.

Hemicrania continua: functional imaging and clinical features with diagnostic implications

This review focuses on summarizing 2 pivotal articles in the clinical and pathophysiologic understanding of hemicrania continua (HC). The first article, a functional imaging project,identifies both the dorsal rostral pons (a region associated with the generation of migraines) and the posterior hypothalamus(a region associated with the generation of cluster and short-lasting unilateral neuralgiform headache with conjunctival injection and tearing [SUNCT]) as active during HC. The second article is a summary of the clinical features seen in a prospective cohort of HC patients that carry significant diagnostic implications. In particular, they identify a wider range of autonomic signs than what is currently included in the International Headache Society criteria (including an absence of autonomic signs in a small percentage of patients), a high frequency of migrainous features, and the presence of aggravation and/or restlessness during attacks. Wide variations in exacerbation length, frequency, pain description, and pain location (including side-switching pain) are also noted. Thus, a case is made for widening and modifying the clinical diagnostic criteria used to identify patients with HC.

Low-dose propofol for the abortive treatment of pediatric migraine in the emergency department

OBJECTIVE

Limited progress has been made in the past decade for abortive treatment of migraine headache in the pediatric emergency department (PED). Propofol, a general anesthetic, has been reported to be effective in the treatment of refractory headaches in adults at subanesthetic doses but never in the pediatric population. The goal of this study was to review our institution's experience with subanesthetic doses of propofol for the abortive treatment of pediatric migraine and compare propofol with standard abortive therapy in the PED.

METHODS

Retrospective review of all patients discharged from the Oregon Health and Science University PED with a diagnosis of migraine headache from January 2010 to July 2011. Patients treated with subanesthetic doses of propofol were compared with matched controls who received standard abortive migraine therapy, defined as the combined use of a nonsteroidal anti-inflammatory medication, diphenhydramine, and prochlorperazine. Outcome variables of interest included reduction of pain as measured on a self-reported visual analog scale and length of stay after administration of initial abortive medication.

RESULTS

Patients who received subanesthetic doses of propofol achieved significantly greater reduction in pain scores (80.1% vs 61.1%; P < 0.05) compared with matched controls as well as shorter stay (122 minutes vs 203 minutes; P = 0.2) after treatment. No adverse effects (hypotension, respiratory depression, or hypoxia) were recorded in either group.

CONCLUSIONS

Propofol seems to be effective for the abortive treatment of pediatric migraine headache in the PED. Further prospective trials are warranted to either support or refute these initial findings.

Effectiveness of intravenous dexamethasone versus propofol for pain relief in the migraine headache: a prospective double blind randomized clinical trial

BACKGROUND

There are many drugs recommended for pain relief in patients with migraine headache.

METHODS

In a prospective double blind randomized clinical trial, 90 patients (age ≥ 18) presenting to Emergency medicine Department with Migraine headache were enrolled in two equal groups. We used intravenous propofol (10 mg every 5-10 minutes to a maximum of 80 mg, slowly) and intravenous dexamethasone (0.15 mg/kg to a maximum of 16 mg, slowly), in group I and II, respectively. Pain explained by patients, based on VAS (Visual Analogue Scale) was recorded at the time of entrance to ED, and after injection. Data were analyzed by paired samples t test, using SPSS 16. P < 0.05 was considered to be statistically significant.

RESULTS

The mean of reported pain (VAS) was 8 ± 1.52 in propofol group and 8.11 ± 1.31 in dexamethasone group at presenting time (P > 0.05). The VAS in propofol group was obviously decreased to 3.08 ± 1.7, 1.87 ± 1.28 and 1.44 ± 1.63 after 10, 20 and 30 minutes of drug injection, respectively. The VAS in dexamethasone group was 5.13 ± 1.47, 3.73 ± 1.81 and 3.06 ± 2 after 10, 20 and 30 minutes of drug injection, respectively. The mean of reported VAS in propofol group was less than dexamethasone group at the above mentioned times (P < 0.05). The reduction of headache in propofol group, also, was very faster than dexamethasone group (P < 0.05). There were no adverse side effects due to administration of both drugs.

CONCLUSIONS

Intravenous propofol is an efficacious and safe treatment for patients presenting with Migraine headache to the emergency department.

TRIAL REGISTRATION

Clinical Trials IRCT201008122496N4.

Improvement of refractory migraine headache by propofol: case series

Background

Several studies have been conducted on managing migraine headaches and developing effective medications for decreasing migraine-associated pain.

Case presentation

Intravenous propofol was prescribed (10 mg every 5 min) for eight patients with intractable migraine headaches visiting the Emergency Department. The average pain score experienced by patients was recorded using the Visual Analogue Scale at the beginning of the treatment procedure and following the injection for 30 min (5-min intervals). The patients’ reported pain scores decreased significantly (P = 0.01) from 8.87 ± 0.83 (CI: 8.17, 9.57) to 1.12 ± 0.83 (CI: 0.43, 1.82) before and 30 min following the injection.

Discussion

It seems that in the treatment of intractable migraine headaches, GABAergic receptors, compared to the normal conditions, have a lower activity status.

Conclusion

Because of the high tendency of propofol to GABAergic receptors, it probably changes this physiological condition by activating the receptors, which results in a significant pain reduction.