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10 Articles in Volume 17, Issue #5
Cross-Linked Hyaluronic Acid Injection for Neuropathic Pain
Discussing Migraine: What to Try When Nothing Is Working
IV Propofol for Treatment of Chronic Intractable Cluster Headache: A Case Series
Letters to the Editor: Rapid Opioid Metabolizer, Intractable Pain, Adrenal Suppression, Traumatic Brain Injury
Migraine Treatment: What’s Old, What’s New
Schizophrenia Spectrum and Chronic Pain: Is Pain Insensitivity a Myth?
Spinal Fluid Flow and Pain Management
Step-by-Step Technique for Targeting Superficial Radial Nerve Pain
The Primary Care Provider’s Role in Diagnosing and Treating Rheumatoid Arthritis
What is the appropriate use of phone texting between physicians and patients?

IV Propofol for Treatment of Chronic Intractable Cluster Headache: A Case Series

Employing an IV anesthetic agent may be highly effective in reducing otherwise unresponsive refractory migraines, making it worthy of consideration as a self-administration option for appropriate patients.
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Sometimes, you serendipitously stumble upon interesting results. I had that experience with the intravenous (IV) anesthetic agent propofol. I use this agent routinely in the clinic as a mild conscious sedative prior to epidural steroid, facet, and other nerve blocks. Some patients who had concomitant migraines at the time of their blocks would comment that their migraine went away before the block was actually performed. This occurred after propofol was given via IV in low conscious sedation doses.

After researching the literature, I found no other mention of this agent in treating migraines or pain. Therefore, I undertook a formal open-label study in the headache clinic to treat refractory migraines unresponsive to usual abortive approaches. A cohort of 77 patients was treated, and the results were dramatic.1

IV propofol is a reasonable option for intractable cluster headaches.

Propofol is the most effective IV agent that I had ever employed, with a 95% success rate in reducing ongoing migraine headaches. The total average dose (subanesthetic) was only 120 mg, given slowly in small, successive increments by IV push, and in small, divided doses. Some patients had features of intractable cluster headaches (CH) and other very painful face-pain syndromes, including trigeminal neuralgia.      

The following 6 case reports present my experience using low-dose IV propofol for the management of intractable CH in my outpatient clinic.

IV Propofol

Propofol is an IV anesthetic with a very good safety profile, and it has been used since the 1960s. Millions of doses are used each year in the United States and worldwide, either as sole anesthesia for surgery and procedures, or as part of anesthesia induction and maintenance.

The specific pharmacologic agonist effect of propofol, with sole effects on subtypes of the gamma-aminobutyric acid (GABA)-A receptor, is a unique mechanism of action, shared partly by other anesthetic agents. Propofol augments inhibitory tone in the central nervous system (CNS) and decreases the rate of dissociation of the GABA from its receptor complex, thereby increasing the duration of the GABA-activated opening of the chloride channel with resulting hyperpolarization of cell membranes. Subanesthetically, it has relative specificity for subsets of GABA-A receptors.

Originally, I showed propofol to be highly effective as subanesthetic IV dosing in eradicating intractable migraines and other headaches, and in many painful disorders.1-6 I am currently exploring its efficacy in eliminating nausea accompanying migraines, headaches, and pain in ultra-low IV doses (20-40 mg per dose).

Cluster Headaches

Cluster headaches are considered among the most disabling of the trigeminal autonomic cephalalgias (TACs), which include cluster headache, paroxysmal hemicrania, and short-lasting unilateral neuralgiform headaches. CH have been described under various eponyms since 1867 (eg, red migraine of Moellendorf), and they are classified as episodic or chronic, largely based on the duration of remissions from the painful unilateral episodes.

In a recent compendium of headache medicine, 13 chapters were devoted to CH and other primarily unilateral TACs.8 CH represents a very small fraction of the total number of migraineurs, typically less than 1% in prevalence. To keep this in perspective, there are more than 100 million people in the United States with headaches, and about 40% of them exhibit migraines or migrainous headaches. This is a small but severely disabled clinical population, and they are extremely difficult to treat in the clinical realm. Although the gold standard for treating migraine—the triptans—have been successfully used, they typically are not effective at treating CH, especially if it has become chronic.

While CH was originally thought to be a short-lived unilateral head pain that was more common in men than women (4:1) (as opposed to migraines, which typically present more in women [3:1]), there has been a decrease in sex ratio over the years. The current observed ratio shows that men are twice as likely to have CH as women (2:1).

Study Design

Because I have a private outpatient clinic that functions, in part, as an emergent care setting for IV treatment of intractable headache and pain disorders, I have extended and amplified the use of several IV anesthetic agents (eg, propofol, ketamine, and lidocaine), and used many so-called “standard” medications over the past 20 years. Some medications are quite proprietary, as they do not exist commercially in this country (eg, IV baclofen and tramadol) and are compounded, based on my research of their physiochemical properties.

Part of the mission of my practice is to provide active intervention to relieve disabling symptoms in a way that may not be possible in the community at large or in a local emergency department (ED) setting. This review attempts to show safety and efficacy of subanesthetic IV propofol in a monitored setting in treating refractory ongoing CH and other TACs.

Whether the patient is in acute distress with a disabling migraine or other pain disorder (often both), or has had an escalating or intractable course of pain or headaches of any nature, we are equipped with the materials necessary for the safe use of IV treatments (dimmable lights in treatment rooms, IV treatment chairs, pulse oximetry monitoring, crash cart, and ACLS/CPR trained personnel [RN and MD] on-site).

All treatments are preceded by an evaluation, including vital signs and physical/neurological examination, to assess the course of treatment. In many cases, the patient is in unremitting pain and headache, and I treat him or her with newer medication approaches that most likely have not been tried or employed. In most cases, it is likely that IV therapies were not used at all in prior treatments (except for opioids, steroids, and antinauseants in the ED). Knowing which medications are compatible with each other in the IV solution (usually normal saline) at the same time can save time in the treatment process strategy. Ideally, 1 agent is tried at a time, starting with low doses based on body weight, and progressing over several administered timed IV propofol dosages. The patient’s rating of the severity of his or her painful symptoms is a vital component of the overall treatment plan in the clinic. Dosages of IV propofol were likely to be higher than those used for refractory migraine headaches in the clinic, as originally studied.1

Last updated on: June 15, 2017
Continue Reading:
Schizophrenia Spectrum and Chronic Pain: Is Pain Insensitivity a Myth?

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