Combined Interventional Treatment of Refractory Chronic Migraine

Abstract

Migraine is one of the main causes of disability in modern world. Treatment of chronic refractory migraine (RCM) would be a challenge even for experienced physician. The aim of this study was to analyze the effect of combination therapy for RCM: greater occipital nerve’s (GON) pulsed radiofrequency (PRF) and botulinum toxin injections. We observed 6 female patients, suffering from RCM according to the European Headache Federation criteria. All patients had long history of migraine (5–44 years) with conservative treatment failure (at least three medication groups). Their migraine could be classified as refractory for long period of time (1–10 years). All of our patients passed a combination of PRF and BTA injection as consecutive 1-day treatments. Botulinum toxin type A injections were done in accordance to the PREEMPT protocol, followed by ultrasound-guided PRF of GONs bilateral. The observation period was 6 months after the procedure. We observed a positive response to treatment in all patients with dramatic reduction of pain intensity (from 7 ± 1 to 2 ± 2 on NRS scale) and significant decrease in the number of headache days (from 22 ± 5 to 4 ± 4) during first month after treatment. Two patients (30%) were pain free after the treatment until the end of the observation. No adverse effects were registered. Bilateral GON’s PRF followed by botulinum toxin therapy as 1-day treatment may be a useful option for the treatment of refractory chronic migraine. These interventional procedures are effective, minimally invasive, inexpensive, safe, and well-tolerated and can be performed on an outpatient basis.

Pulsed Radiofrequency Neuromodulation of the Greater Occipital Nerve for the Treatment of Headache Disorders in Adults: A Systematic Review

“…Full texts of 7 articles were assessed for eligibility, of which 1 study was deemed to meet all eligibility criteria for inclusion in this review. Finally, two RCTs, 31 , 32 four prospective cohort studies, 33–36 seven retrospective cohort studies, 37–43 two case series, 44 , 45 and 7 case reports were included. 46–52 A summary of the original search strategy is described in Figure 1 (PRISMA Original Search) and the updated search in Figure 2 (PRISMA Updated Search).…”

“…Three different interventional targets were found: PRFN was applied at the level of C2 DRG in eight studies, 35 , 40–42 , 46 , 49 , 50 , 52 as a “distal GON approach” in 11 studies, 31–34 , 36 , 37 , 39 , 43 , 44 , 47 , 51 in a “proximal GON approach” in three studies. 38 , 45 , 48 …”

“…Treatment parameters for PRFN consisted of one, 31–38 , 40–43 , 45 , 46 , 48–52 two, 39 , 47 or three 44 cycles on a temperature of 42°C for a duration of 90 40 or 120 39 , 42 , 47 , 49 , 51 to 360 34 , 38 , 43 , 45 , 48 seconds at 40–60 volts. 31 , 34 , 36 , 38 , 39 , 42 , 43 , 48 , 50 Two outliers reported one cycle of 900 seconds.…”

Treatment of resistant chronic migraine with anti-CGRP monoclonal antibodies: a systematic review

“…Furthermore, a survey for physicians involved in migraine care, carried out by the European Headache Federation with the endorsement of the European Migraine & Headache Alliance, demonstrated the necessity of more evidence regarding the management of these patients as well as clearer guidelines for physicians [ 92 ]. Other forms of action such as combined treatments, as presented in the study carried out by Voloshin and co-workers [ 93 ], may represent opportunities that should not be neglected and could be important to explain the mechanisms which contribute to drug resistance in migraine. Finally, there are no data about head-to-head comparison between distinct anti-CGRP mAb, so primary studies will also be needed to improve the evidence-based data.…”

Conceptualising migraine attacks from a biopsychosocial model using qualitative and functional behavioural analysis

“…If patients need to take more than eight doses of emergency medicine per month, preventive drug treatment is recommended [ 10 ]. In difficult-to-treat chronic migraine, medical combination treatments of preventive measures are used [ 13 ].…”