Although methocarbamol is an older muscle relaxant preparation with uncertain pharmacologic mechanism(s) of action, it is one of the very few available in an IV form and, for this reason, I sometimes use it in the clinic to treat migraines and other headaches—especially if accompanied by a lot of neck spasms. 3. Krusz JC, Longmire DR. Tramadol in the treatment of headaches. The average dose was 423 mg (range: 250-1,100 mg), given over 95 minutes in our clinic. Traumatic brain injury. Migraine-type headaches in children receiving chemotherapy and ondansetron. Divalproex sodium (Depakote), as an enteric-coated preparation, was approved in 1994 for oral use in the prophylaxis of migraines in the United States. Gallagher RM. Mauskop A, Altura BM. In the future, we will undoubtedly have more unique pharmacologic agents to treat post-TBI migraines more effectively. September 1998. The injured person's eyes may remain closed, and the person may not show signs of awareness. Baclofen is a GABA-B receptor agonist, a unique mechanism of action. Sedation and cognitive side effects, such as confusion or memory problems, however, may limit the use of topiramate. The total dose (subanesthetic) was only 120 mg, given slowly by IV push 20 mg at a time. The author has used venlafaxine (Effexor), duloxetine (Cymbalta), and milnacipran (Savella) off-label in his clinical practice. Stop football…save brains: a point counterpoint discussion. May 2013: Abstract 378. Just as two people are not exactly alike, no two brain injuries are exactly alike. Intravenous lignocaine (lidocaine) infusion for the treatment of chronic daily headache with substantial medication overuse. Oxcarbazepine as migraine prophylaxis. Peres MFP, Zukerman E, Soares C, Augusto S, Alonso EO, Santos BFC, Faulhaber MHW. Letters to the Editor: Testosterone, Ultra-high Dose Opioids. New Orleans, Louisiana. We undertook a formal open-label study in the headache clinic to treat refractory migraines unresponsive to usual abortive approaches. Lamotrigine for chronic neuropathic pain. 1-4 Studies to date have documented that anywhere from 30-90% of individuals who sustain a mTBI develop post-traumatic headache. He is also involved in treatment trials for idiopathic intracranial hypertension. A severe head injury can result in pressure being placed on the brain because of bleeding, blood clots or a build-up of fluid. Baclofen IV in the clinic: effective treatment for muscle spasm pain and migraines. Kaube H, Herzog J, Kaufer T, Dichgans M, Diener HC. 56Krusz JC. August 2003. Therefore, approach to neurological rehabilitation and physiotherapy post-traumatic brain injury should observe neuroplasticity, motor learning, and motor control principles as well as the patient-centred approach with an individual’s goals settingand choice of treatment procedures. It also blocks N-methyl-D-aspartic acid (NMDA)–type glutamate excitatory amino acid activity, and nitric oxide synthesis and release—all of which are factors in migraine pathophysiology or maintenance. What is a cognitive disorder after a traumatic brain injury? You can find further information regarding our expertise, experience and team on our Personal Injury page. Additional surgery may include: 1. We always have a patient acknowledge this for any treatment, oral or IV, and document this in their chart and on paper. Two studies found poorer outcome in the lidocaine-treated patients than with DHE, chlorpromazine treatment IV,57 or against placebo.58 The response to IV lidocaine was better in chronic daily headache in two retrospective studies.59,60 We have re-explored IV lidocaine for treatment of refractory migraines and have shown some promising data.61,62 However, this was an off-label use of lidocaine and, due to its ability to block neuropathic pain, it may play a roll in the treatment of refractory migraine post TBI. In the first few weeks after a moderate to severe brain injury, swelling, bleeding or changes in brain chemistry often affect the function of healthy brain tissue. FDA warns pregnant women to not use certain migraine prevention medicines. The IV preparation of tramadol turned out to be very efficacious, very well tolerated, rapidly treated refractory migraines and mixed headaches, and gave me another tool to use in the clinic when other agents failed.75 Our most recent accumulated data were presented this year. 32nd Annual Scientific Meeting of the American Pain Society. Specific Measurable Achievable Relevant Timed goals and patient’s involvement in goal setting allows the clear orientation of the rehabilitation process and en… The fields of pain and headache management use common terminologies to describe these processes. Jensen R, Brinck T, Olesen J. Webinar recording: Stewarts Soundbites Episode 12 – Rental Properties after Serious Injury; Obstacle or Opportunity? July 1999. We developed an IV form of the same agent (with a compounding pharmacy) and evaluated levetiracetam IV in the treatment of refractory migraines. American Academy of Pain Management Annual Meeting. This month, our author tackles treatment of TBI headaches. Opioid Prescribing and Monitoring - Second Edition, Opioid Prescribing and Monitoring - First Edition. Source: Our health information content is based on research evidence whenever available and represents the consensus of expert opinion of the TBI Model System directors. Prophylaxis for chronic daily headache and chronic migraine with neuronal stabilizing agents. Psychosis after traumatic brain injury (TBI) is a relatively uncommon condition that presents both clinical and conceptual challenges. 7th Congress European Federation of Neurological Societies. The bottom line on preventative therapy for post-TBI headaches and migraines is to look for comorbidities that are present along with the headaches and to treat with an agent that can reduce the migraine frequency and severity and the comorbid clinical state. Krusz JC. 47th Annual Scientific Meeting of the American Headache Society. Removing clotted blood 2. Chicago, Illinois. Philadelphia, Pennsylvania: June 2005. An older ED study using IM prochlorperazine compared with metoclopramide found the former to be more reliable in reducing headache to the endpoint of the study (1 hour). Lidocaine is an indiscriminate blocker of sodium (Na+) channels. In severe cases, a doctor might recommend surgical interventions to treat tremors after brain injury. Fourth International Congress on Neuropathic Pain. I use it in an intrathecal sterile form (Gablofen) for epidural and facet blocks, but a commercially available IV form is not available in the United States. This term would be used in an all-inclusive fashion and under its umbrella all medical, psychological and other diagnoses from post-tbi would be included. (DSM III) in 1980, and since that time a great deal of knowledge has accumulated about the characteristics of post-traumatic symptomatology, the epidemiology of PTSD, and assessment and treatment of individuals suffering from this disorder. I had originally published data with the oral form of the medication in treating headaches74 and was impressed by its ability to treat chronic headaches and migraines. Elvis Presley: Head Trauma, Autoimmunity, Pain, and Early Death, Traumatic Brain Injury: Treatment of Post-traumatic Headaches, Advances in Pharmacologic Pain Management of Juvenile Idiopathic Arthritis, Integrative Treatment Approaches for Juvenile Idiopathic Arthritis, How Changing Hydrocodone Scheduling Will Affect Pain Management, Editor's Memo: Interpreting Indications For Electromagnetic Therapy. Relieving pressure in the skull Medications These medications may include, but are not limited to: 1. Please add updates@practicalpainmanagement.com to your address book to ensure delivery. The Brain Injury Network (BIN), a brain injury survivor advocacy organization, recommends the emphasis of a traumatic brain injury (TBI) classification entitled Post TBI Syndrome. Coronado, McGuire, Faul, Sugerman, Pearson. In my opinion, the ideal headache clinic would offer a large number of IV services and be staffed by nurses trained in IV therapy and monitoring with pulse oximetry. Other agents in this large group were also studied for migraines, chronic daily headaches, and neuropathic pain by the same author.11 Unfortunately, in the vast majority of these studies the industry chose not to study the medication formally in a double-blind, placebo-controlled fashion. OBJECTIVES To better establish the clinical features, natural history, clinical management, and rehabilitation implications of dysautonomia after traumatic brain injury, and to highlight difficulties with previous nomenclature. It consists of three parts: Acute treatment of post-TBI headaches using migraine-specific therapy, prophylactic therapy to suppress post-TBI headaches, and interventional treatments used in our outpatient headache clinic. While head injuries are one of the most common causes of death and disability in the United States, many patients with head injuries are treated and released from the emergency department after receiving treatment. IV baclofen for treating migraines accompanied by severe muscle spasm in an outpatient setting. Stimulants Rehabilitation T… Post-traumatic stress disorder (PTSD) can develop after a very stressful, frightening or distressing event, or after a prolonged traumatic experience. Quite frankly, the "classic" migraine-specific abortive medications used for treatment of acute migraines and migrainous headaches—for example, dihydroergotamine (DHE-45) and triptans—are FDA indicated for moderate to severe migraines. Krusz JC, Belanger J. A traumatic brain injury can lead to many changes in a person’s life. There is substantial literature on the use of IV magnesium for migraines and cluster headaches.19-22 The original studies by Mauskop and colleagues studied ion-sensitive Mg++ electrodes to measure ionized magnesium, a technique not commonly available. Comparison of dihydroergotamine with metoclopramide versus meperidine with promethazine in the treatment of acute migraine. King MA, Bradshaw S, Chang AH, Pintar JE, Pasternak GW. A small child should always sit in the back seat of a car secured in a child safety seat or booster seat that is appropriate for his or her size and weight. The key is to have a wide and varied repertoire of interventions to address each unique patient's pain presentation. Traumatic events that can result in PTSD fall into … Anticoagulants 3. Repairing skull fractures 3. A traumatic brain injury (TBI) is an injury that has occurred as a result of trauma to the head. Most often these have the characteristics of migraines, migrainous headaches, and mixed tension-type headaches (TTH) and migraines, as was discussed in Part 1 of this series.1 There have been a number of recent articles in medical journals that have renewed the debate about TBI, including an article by Robbins and Conidi on sports-related injuries. It was the first anticonvulsant molecule to be found useful in treating migraines in a prophylactic manner.44-46 An IV version of valproate sodium (Depacon) was developed and was used for treatment of seizures. As swelling decreases and blood flow and brain chemistry improve, brain function usually improves. Ginder S, Oatman B, Pollack M, A prospective study of IV magnesium and IV prochlorperazine in the treatment of headaches. IV baclofen: treatment for refractory migraines and daily headaches C0-morbid with muscle spasm in the outpatient clinic. The future of aggressive pain and headache treatment of TBI-related headaches will reside in the sphere of the specialist's clinic. Traumatic brain injury (TBI) is a leading cause of cognitive impairment that affects millions of people worldwide. They are indicated for moderate to severe migraines, but early intervention in the migraine process is always desirable. The original IV DHE protocol to treat refractory migraine headaches was introduced in 1986 by Professor Raskin and it became the mainstay of inpatient and in-clinic treatments.40 Typically, DHE (1 mg) is given every 8 hours with IV metoclopramide 10 mg for 2 to 3 days. – Occupational Therapist Kate Meads gives an expert’s guide. Muscle spasm and pain as distinguished from migraines were rated by patients using a VAS every 15 minutes. It uses surgically implanted electrodes to send high-frequency signals to the thalamus, the structure in the brain that controls involuntary movements. METHODS Retrospective file review on 35 patients with dysautonomia and 35 sex and Glasgow coma scale score matched controls. He explains whether it is possible to distinguish between the pervasive and chronic symptoms compared to those which may be addressed by assessment and treatment. Depending on the severity of injury, a family caregiver or friend may need to help implement the following approaches: 1. Multiple types of headaches, including migraines, migrainous headaches, TTH, and cluster headaches responded to IV magnesium therapy.19 The headache sufferers with the best and longest response to this treatment also had the lowest ionized Mg++ levels, both for migraines as well as for cluster headaches.20 One study has summarized clinical data with IV MgSO4 using doses of 0.5 to 1 g.23 In general, the author uses higher doses than that, and typically uses 2.5 to 3 g.21,22, Antiemetics have been used along with acute opioid therapy for headaches and for pain treatment. May 2013: Abstract 381. Droperidol treatment of status migrainosus and refractory migraine. Williams DR, Stark RJ. 7th European Federation of Neurological Societies. In this episode, Emma Lyons and Dr Silver discuss the origins of fatigue after traumatic brain injury as well as the potential treatable causes. Flores JA, El Banoua F, Galan-Rodriguez B, Fernandez-Espejo E. Opiate anti-nociception is attenuated following lesion of large dopamine neurons of the periaqueductal grey: critical role for D1 (not D2) dopamine receptors. Ketamine in an outpatient setting: effective treatment for neuropathic pain syndromes. Tampa, Florida. Formal trials of IV lidocaine to treat acute migraine headache were published some time ago. More data are available for the treatment of cluster headaches, status migrainosus, or analgesic rebound headaches.37 We frequently use dexamethasone (2-4 mg every 8-12 hours, as needed) for severe, refractory migraines along with IV MgSO4. Cognitive impairment is common after TBI, with treatment limited by the heterogeneity of injuries. Methods: A total of 100 individuals with persistent post-traumatic headache attributed to mild traumatic brain injury were enrolled between July 2018 and June 2019. Cost effectiveness of clinic treatment of headaches and pain. Off-label use of medication is perfectly legitimate as long as the clinician explains that to the patient. Krusz JC, Robbins L. Traumatic brain injury. Of course, we make every effort to use one medication at a time and to carefully document the percentage of pain reduction of that single agent. Our initial data with migraines77 have since grown in numbers and types of migraines treated78,79 and these include post-TBI migraines with severe muscle spasms. Currently available treatments have limited efficacy. Thus, keeping doses quite low (around 2 mg total) can be very effective and I have quite a number of patients who use IM droperidol at home as rescue medication for their migraines—either with migraine-specific therapy or to avoid a trip to the ED. Memantine for treatment of cognitive deficits after traumatic brain injury. Unger J, Cady RK, Farmer-Cady K. Understanding migraine: treatment options. One of the initial studies using IV droperidol used quite high doses (mean 16.6 mg) and reported nearly all of their patients being sedated and more than 50% having extrapyramidal symptoms 24 hours after treatment.31 We repeated the study in our clinic using from one fifth to one quarter of the dose of IV droperidol with only 3% side effects and well over 50% success rate in reducing or eliminating refractory migraines.32 A double-blind trial of IM droperidol,33 again using high doses of the medication, showed efficacy; the placebo response rate was 57% vs 84% for droperidol. June 2011: Abstract 15. American Academy of Pain Management Annual Meeting. A TBI often damages the front part of your brain, which is the part of the brain used for thinking and memory. Accessed May 6, 2013. May 2013. Krusz JC, Daniel D, Cagle J. IV Levetiracetam efficacious for cluster headache. You can change your cookie settings at any time. Emergency treatment of intractable migraine. We have also anecdotally looked at small numbers of patients with painful disorders like trigeminal neuralgia, complex regional pain syndrome (CRPS), and other pain flare-ups and they seem to also respond to propofol (unpublished data). Cammarata D, Krusz JC. It was noted that some patients who had migraines at the time of their blocks would comment on eradication of the migraine before the block was performed, but after propofol was given. The first two medications were originally approved as anticonvulsants, but were found to be effective in managing migraine, chronic daily headaches, and cluster headaches. Also, ergotamine is fraught with the possibility of rebound migraines and headaches (now termed "medication overuse headache"), whereas DHE does not have this property. We have used this agent routinely in the clinic as a mild sedative prior to epidural steroid and facet nerve blocks in a conscious sedation manner. April 2009: Abstract 221. There is a growing body of evidence that a blockade of central dopamine receptor systems can enhance anti-nociception or the pain-relieving analgesic properties of opioids.27-29 One study of neuropathic pain suggested that bupropion might decrease neuropathic pain via an effect on presynaptic reuptake of dopamine.30 These properties might explain the ability of dopamine blockers, like metoclopramide or droperidol, to reduce migraine headaches—an effect we and others have noted in the clinic setting in the treatment of migraines. Controlling blood pressure 3. Seat belts and airbags. Time: 1:00 -­ 1:15pm. The starting dose is 0.625 mg of IM droperidol, repeated after 20 to 30 minutes, and once again if needed. Intravenous valproate sodium in the treatment of refractory migraine headaches. The second part of this series specifically addresses the treatment of PTH and does not claim to be comprehensive. 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