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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
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.
Patient presented with severe migraine headaches had complete resolution of migraine headaches with low-dose intrathecal ziconotide.
The patient had a
history of peripheral polyneuropathy and pain affecting the legs as well as
severe, chronic migraine headache.
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.
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.
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.
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.
J Pain Res. 2015; 8: 603–606.
Resolution of chronic migraine headaches with intrathecal ziconotide: a case report
Sachin Narain et al.
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