Intravenous Lignocaine Infusions for Severe Chronic Daily Headache

The following is taken from a report written by Dr P.J Hand and Dr R.J Stark and published in the Medical Journal of Australia:

Abstract

Objectives: To determine the safety and the efficacy of intravenous lignocaine infusion in patients with severe chronic daily headache (CDH).
Design: Retrospective survey of consecutive patients.
Participants: 19 patients, 18 with rebound headache and three with status migrainosus. Two patients had both conditions at different times.
Setting: Neurology unit in a major metropolitan teaching hospital, 1994 - 1998
Main outcome measures: Adverse events; headache resolution; long term efficacy.
Results: The 19 patients (16 women) received 27 lignocaine infusions. Seven minor adverse events were noted during four infusions. Twenty-two infusions were given for analgesic rebound headache in 18 patients, with headache resolution in 82% of infusions (17 of the 18 patients responded at least once).
Four patients obtained lasting relief, six returned to their regular manageable pattern of migraine (in two of these patients CDH recurred after six months), four were lost to follow up, and in four there was no long term benefit. Five infusions were given for status migrainosus in three patients, with four of these infusions successfully relieving the headache.
Conclusions: Intravenous lignocaine appears to be useful in the management of severe intractable CDH and status migrainosus.
MJA 2000; 172: 157-159.

Managing patients with intractable severe, chronic daily headache is a challenge for neurologists. While chronic daily headaches (CDH) occur in 4% of the population, most are mild or moderate, and easily managed. However, in a small group of patients, the headaches are so severe that the patients present regularly to emergency departments or general practitioners' surgeries requiring narcotic analgesics.

Most patients with this severe variety of CDH have a background of episodic migraine that becomes a chronic headache, usually because of medication misuse. The patient develops tolerance to the medication, resulting in a cycle of analgesic use in increasing doses and rebound headache on withholding the drug. If the medication can be discontinued, the headache eventually improves.

This remains the cornerstone of management; the difficulty in maintaining pain control while withdrawing the analgesic. Many medications have been suggested to break the pain cycle, but in some patients, the condition does not respond to any form of ambulatory therapy.

Intravenous lignocaine infusions have been proposed by Professor Jim Lance, as therapy for prolonged, severe migraine ("status migrainosus") but there are no published reports of use of lignocaine specifically for rebound headache (although some of the patients with CDH described by Dr. Kaube may have had rebound headache).

We have been performing lignocaine infusions occasionally for severe headache since the early 1980s. Since 1994, infusions have been used according to a defined protocol as part of inpatient management of CDH. Our aim was to document the safety and efficacy of this treatment, particularly the safety of prolonged infusions for severe rebound headache, allowing withdrawal of analgesic or ergotamine.

Patient Management

The lignocaine infusion was part of a comprehensive inpatient management protocol. If possible, patients received a psychiatric assessment and (if necessary) treatment. Detailed education was provided regarding the nature of rebound headache and the need to avoid all analgesics containing codeine. Prophylactic medication for migraine, such as pizotifen or clonidine was permitted and was commenced during the hospital stay.

1. Protocol for Lignocaine Infusions for Chronic Severe Daily Headache

• Indications: Rebound headache or a prolonged, severe migraine unresponsive to other therapy. For patients with analgesic rebound headache, all analgesics are withheld during the infusion.
• Contraindications: Significant cardiac disease, epileptic seizures,  severe degrees of sinoatrial, atrioventricular or intraventricular heart block, or allergic reaction to lignocaine.
• Procedure: A 12-lead electrocardiogram (ECG) is obtained and examined before and 30-60 minutes after starting the infusion. Lignocaine is delivered by a pump device at a rate of 2mg / min (no bolus is given).
• Observations: The patient is attached to a bedside cardiac monitor, and a rhythm strip is obtained every 5 minutes for the first 30 minutes then every 15 minutes for 3 hours, and thereafter every 2 hours. Pulse rate and blood pressure are measured every 5 minutes for first 30 minutes, then every 15 minutes for 3 hours, and thereafter every 2 hours while the patient is awake.
• Duration: the infusion is maintained until the patient has been headache free for at least 12 hours. The duration of infusion should not exceed 14 days.

2. Results of Lignocaine Infusion - Rebound Headache Group (22 infusions in 18 patients)

Headache History.

• Transformed Migraine - 14 patients
• Tension-type headache - 4 patients
• Duration of chronic daily headache (CDH) - median 5 months (range, 2 weeks - 6 years)

Use of Analgesics

• All patients used compound analgesics (median codeine intake 150mg / day [range, 48-300mg / day])
• Four patients required additional weekly parenteral narcotic (pethidine or morphine); one used 300mg / day oral pethidine.
• Two patients used ergotamines daily.

Psychiatric Assessment (11 patients, 3 refused)

• All had strong functional components to their illness. 4 had personality disorders, 2 had depression.
• In 4 patients a "trigger" was identified (e.g. maternal illness, grief reaction, domestic violence)
• Intervention included psychotherapy (recommended in 8 patients, refused by 3); antidepressants given to 2 patients

Lignocaine Infusion

Outcome

• Successful in 15 infusions in 14 patients (no additional treatment required for pain)
• Partially successful in 3 infusions in 3 patients (some supplemental use of dihydroergotamine)
• Unsuccessful in 4 infusions in 3 patients

Duration of Infusion

• Median, 5 days (range, 9 hours - 12 days)
• Infusions lasting 6 days and longer - 90% were successful.
• Infusions lasting 5 days or less - 64% were successful.

Duration of Admission

• Median, 7 days (range, 2 - 15 days)

3. Results of Lignocaine Infusions - Status Migrainosus Group (5 infusions in 3 patients)

Headache History

• All had a history of migraine headache
• Duration of headache: median 7 days (range 2 - 14 days)

Psychiatric Assessment
(Obtained in one patient who had three infusions)

• Personality disorder with dependent traits. "Enjoys the role of being ill."

Lignocaine Infusion
Outcome

• Successful in 4 infusions in 3 patients (as sole therapy)
• Partially successful in one infusion in one patient (headache resolved. But supplemental intravenous dihydroergotamine was required)

Duration of infusion

• Median, 24 hours (range: 10 - 72 hours)
• Resolution of headache occurred after a median of 24 hours (range 10-24 hours: mean 19 hours)

4. Adverse Events During Four Lignocaine Infusions

• Raised potassium level (to 6.4mmol/L) - lignocaine infusion was stopped and potassium level remained elevated, possibly due to coexisting pyelonephritis.
• Transient hypotension (to 75/50 mmHg) immediately after administration of intramuscular droperidol for agitation - lignocaine infusion was continued and the blood pressure level improved over several hours.
• Rhythm strip abnormality (not specified in patients record) on day 3 - 12-lead ECG gave normal results, and lignocaine infusion was continued. Transient bradycardia (to 50 beats / min) while patient slept - lignocaine infusion was continued
• Chest pain at 12 hours with normal ECG findings - infusion stopped for one hour, then recommenced without problem.  Fever at 24 hours with no apparent cause - infusion ceased but headache recurred, so lignocaine infusion recommenced. Intractable nausea at 72 hours - lignocaine ceased. Nausea persisted for several weeks with no cause identified.

Dr Peter J Hand Neurology Registrar, Dr Richard J Stark Consultant Neurologist, Alfred Hospital, Commercial Road, Prahran Vic 3181.
Medical Journal of Australia, 21 February 2000, Volume 172, No. 4