Peripheral Nerve Blocks in the Treatment of Migraine in Pregnancy

Govindappagari, Shravya; Grossman, Tracy B.; Dayal, Ashlesha K.; Grosberg, Brian M.; Vollbracht, Sarah; Robbins, Matthew S.

doi:10.1097/aog.0000000000000555

Cited by 65 publications

(39 citation statements)

References 30 publications

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“…Only 4 patients in our study received peripheral nerve blocks with lidocaine, another effective treatment considered safe in pregnancy due to lack of systemic effects. In a previous study, drawing from a similar population as the current study as well as in the outpatient setting, 11 of 13 pregnant patients who received peripheral nerve blocks safely experienced improvement in headache after the procedure …”

Section: Discussionmentioning

confidence: 91%

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Migraine Treatment in Pregnant Women Presenting to Acute Care: A Retrospective Observational Study

Hamilton

Robbins

2018

Headache

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Objective.-To assess the acute treatment of pregnant women presenting to a hospital with migraine. Background.-Migraine is a common problem in pregnancy; however, migraine treatment is challenging in pregnant women for fears of medication teratogenicity and lack of data in this population. To date, no study has directly explored physician practices for treatment of acute migraine in pregnant women.Methods.-We conducted a retrospective chart review of medication administration for pregnant women who presented to an acute care setting with a migraine attack and received neurology consultation between 2009 and 2014.Results.-We identified 72 pregnant women with migraine who were treated with pain medications. Fifty-one percent (37/72) were in the third trimester of pregnancy, 39% (28/72) in the second trimester, and 10% (7/72) in the first trimester. Thirty-two percent (23/72) had not tried any acute medications at home before coming to the hospital, and 47% (34/72) presented in status migrainosus. Patients received treatment in the hospital for a median of 23 hours (interquartile range = 5-45 hours). The most common medications prescribed were metoclopramide in 74% (53/72) of patients (95% confidence interval [CI] 62-82%) and acetaminophen in 69% (50/72) of patients (95% CI 58-79%). Metoclopramide was administered along with diphenhydramine in 81% (44/53) of patients (95% CI 71-91%). Acetaminophen was the most frequent medicine administered first (53%, 38/72). Patients were often treated with butalbital (35%, 25/72) or opioids (30%, 22/72), which were used as second-or third-line treatments in 29% of patients (20/72). Thirty-eight percent (27/72) received an intravenous (IV) fluid bolus, 24% received IV magnesium (17/72), and 6% (4/72) had peripheral nerve blocks performed.Conclusions.-While the majority of pregnant women with acute migraine received medications considered relatively safe in pregnancy, there was variation in treatment choice and sequence. Some acute medications considered potentially hazardous for fetal health and less effective for migraine (opioids and butalbital) were used frequently, whereas other treatments that may have low teratogenic risk (nerve blocks, IV fluid boluses, and triptans) were used less or not at all. These results indicate a need for developing guidelines and protocols to standardize acute treatment of migraine in pregnancy.Abbreviations: CI confidence interval, ED emergency department, IQR interquartile range, IV intravenous, NSAID nonsteroidal antiinflammatory drug.

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Section: Discussionmentioning

confidence: 91%

“…Our study population was derived from a consecutive series of pregnant patients with headache who received a neurology consultation either in the ED or after hospital admission. This patient population was previously studied for other aspects related to headache and pregnancy . Subject number was based on the available data.…”

Section: Methodsmentioning

confidence: 99%

Migraine Treatment in Pregnant Women Presenting to Acute Care: A Retrospective Observational Study

Hamilton

Robbins

2018

Headache

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“…Peripheral nerve blocks are used for both short-term migraine prophylaxis as well as the treatment of status migrainosus. [58]…”

Section: Magnesium and Riboflavinmentioning

confidence: 99%

Headache in Challenging and Special Circumstances: Pregnancy and Lactation

Yılmaz¹,

Çevik

2018

Agri

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ÖzetGebelik ve doğum sonrası dönemdeki baş ağrıları özel bir önem taşımaktadır. Bu dönemdeki baş ağrısı yönetimi sağlık çalışanları ve hastalar tarafından zorlayıcı olarak bildirilmektedir. Başağrısına doğru yaklaşım hem anne hem de fetal/yenidoğan risklerinin önlenmesi açısından önemlidir. İlk trimesterdeki baş ağrılarının büyük çoğunluğu primer baş ağrıları grubundadır. Gebeliğin son trimesteri ve doğum sonrası dönemlerde, sekonder baş ağrılarının sıklığı ise artmaktadır. Baş ağrısı hastalarında kırmızı bayrak belirti ve bulgularına dikkat edilmelidir. Baş ağrısı hastasının değerlendirilmesinde detaylı anamnez alınması; doğru ve eksiksiz olarak fizik ve nörolojik muayene yapılması yanında gerekirse ileri tetiklerin yapılması da önemlidir. Bu derlemede gebelik ve laktasyon dönemindeki baş ağrılarına yaklaşım ve en iyi medikal uygulama stratejileri gözden geçirilmektedir. Anahtar sözcükler: Tanı; migren; primer baş ağrıları; kırmızı bayrak bulguları; sekonder baş ağrıları; tedavi. SummaryHeadache has special importance during pregnancy and postpartum period. The health-care professionals and patients report headache management as challenging during pregnancy and lactation period. Cautions are recommended in preganancy and lactation due to maternal and fetal/newborn risks. Most headaches in the first trimester are due primary headaches. Nevertheless, the incidence of secondary headaches increase in the last trimester and post-partum period. Red flags prompt early evaluation in a patient with headache. Assessment of headache patient requires a detailed history of the headache characteristics and performing appropriate examinations. Approach to headache and strategies to promote best practice in preganancy and lactation will be reviewed.

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“…15 In a recent retrospective study, the authors examined the use of PNBs in 13 pregnant women with refractory migraine. 36 Different nerve blocks were performed, including ONB using lidocaine. The procedure was effective in all but 2 patients.…”

Section: Expert Opinionmentioning

confidence: 99%

Occipital and Trigeminal Nerve Blocks for Migraine

2015

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To block or not to block, that is the question. CLINICAL HISTORIESCase 1.-This is a 53-year-old male seen for consultation due to headaches since high school, which have been almost daily for the past 20 years. He describes a throbbing pain behind the left eye, with an intensity of 5-9/10 and posterior cervical pressure, occasionally associated with nausea and vomiting, but no light or sound sensitivity. He takes rizatriptan 10 mg daily, and the headache is gone in about 1 hour. Every couple of weeks, the headache recurs and he takes another dose of rizatriptan. He takes hydrocodone 1-2 tablets every couple of weeks. Alcohol triggers his headaches. Sumatriptan injections and baclofen did not help. He has tried topiramate, amitriptyline, divalproex sodium, gabapentin, and propranolol for headache prevention, without help. He also tried onabotulinumtoxinA once, without help. Chiropractic treatment did not help. He has not tried acupuncture. Magnetic resonance imaging of the brain with and without contrast, done 3 months previously, was negative. He has a past medical history of hyperlipidemia, treated with a statin. Neurological examination was normal. There was bilateral greater occipital nerve (GON) tenderness. Bilateral greater occipital nerve block (GONB) was performed by injection of 3 mL of 1% lidocaine 2 cm lateral and 2 cm inferior to the inion on each side. For headache prevention, he was started on zonisamide 100 mg daily for 2 weeks and then 200 mg daily. He was informed on the risk of medication overuse headache with frequent use of rizatriptan. He was seen in follow-up 2 months later. During the 2 weeks after the occipital nerve blocks (ONBs), he had one headache that was quickly relieved by rizatriptan. For the following 14 days, he experienced headaches once every other day, and thereafter his daily headache pattern resumed, with prompt relief by rizatriptan.Case 2.-This is a 45-year-old woman with a 15-year history of migraine without aura occurring about 2-3 times per month. She takes eletriptan 40 mg tablets, with relief of the headache in 2 hours. She presents with a 2-day history of a typical right-sided throbbing headache of 9/10 intensity, associated with nausea, vomiting, as well as light and sound sensitivity. Her symptoms did not respond to 2 doses of eletriptan and promethazine suppository. A right GONB was performed by injection of 3 mL of 1% lidocaine 2 cm lateral and 2 cm inferior to the inion, with relief of the headache within 10 minutes. Subsequently, she has had 2 similar episodes that were quickly relieved by ONBs.Case 3.-This is a 58-year-old male seen in consultation with headaches since high school, which have been daily for the past month. Prior to that, he had approximately 4 headache days per week for many years. He describes a bilateral retro-orbital and temporal pain with nuchal-occipital throbbing and pres-

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Peripheral Nerve Blocks in the Treatment of Migraine in Pregnancy

Abstract: Peripheral nerve blocks for treatment-refractory migraine may be an effective therapeutic option in pregnancy.

Cited by 65 publications

References 30 publications

Migraine Treatment in Pregnant Women Presenting to Acute Care: A Retrospective Observational Study

Migraine Treatment in Pregnant Women Presenting to Acute Care: A Retrospective Observational Study

Headache in Challenging and Special Circumstances: Pregnancy and Lactation

Occipital and Trigeminal Nerve Blocks for Migraine

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