A Case of chronic migraine headaches treated with intrathecal ziconotide
A 57-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 stated to have experienced almost 20 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 ployneuropathy. Since the patient was already diagnosed with migraine, she had tried a variety of pain relieving medications including ibuprofen and other NSAIDs but in vain. Other medication history included beta-blockers, anticonvulsants, anti-anxiety drugs and Botox injection. She also had a Botox injection which decreased frequency of migraine attacks to three attacks a month and also reduced the overall intensity of pain.
The most likely diagnosis of this presentation is
- Unexplained Headache
- Migraine headache
- Multiple sclerosis
- Trigeminal neuralgia
Migraine refers to a recurrent headache (mostly unilateral or sometimes bilateral) often accompanaid by nausea, vomiting, photophobia, phonophobia, and hyperosmia. Migraine may occur with or without aura. Aura symptoms generally include altered vison, focal motor seizures may occur as part of the aura spectrum. Migraine is a very common disorder affecting almost 12% of the Western population, especially women between the ages of 22 and 55 years. Though it may affect anyone , it is more common in felames, accounting to 3-10% of the female population. While the prevalence is 1–4 % in the male population.1 The higher prevelance in females ay be attributed to menarche, menstruation, pregnancy, and menopause as use of oral contraceptives and of hormone replacement treatment (HRT).2 Severe migraine is ranked in the highest disability class by the World Health Organization. 3 Migraine may affect wellbeing and overall quality of life and also the other achievements in life. It is estimated that approximately 30 % of migraine affected individuals either remain undiagnosed/misdiagnosed or inadequately treated.1
Since the patient was already been 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 initially started, with the flex dosing, she received 10.98 µg of baclofen and 0.1230 µg of ziconotide every four hours (6 doses/day). The flex doses are given over a period of 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 she did not experience any migraine attack during this treatment duration.
The present case study reports an incidental discovery of ziconotide treatment that completely relieved the symptoms of chronic headaches with migraine features. Migraine remains an elusive and poorly understood disease and the treatment approach is oftem categorized as preventive and abortive approaches. Preventive approach involves variety of medications including antihypertensives, antidepressants, antiepileptics, Botox injection, and supplements, esoecially to manage episodic migraine than chronic migraine. Abortive approaches include triptans, egortamine derivatives, and NSAIDs.4
Ziconotide, is an intrathecal analgesic drug , often used as an important 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 a 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 recommended as an initial doses , while 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.5
Initial evidences have confirmed the feasibility and usefulness of intrathecal ziconotide in the management of refractory chronic pain. According to Saulino M. et al,6 combination intrathecal ziconotide and baclofen therapy may be a treatment option for patients with neuropathic pain and spasticity.6
As such, there are no case reports of migraine headaches treated with Zinconotide, but a case of trigeminal neuralgia improved with intrathecal ziconotide is evidenced.4 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.
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Sacco S, Ricci S, Degan D, and Carolei A. Migraine in women: the role of hormones and their impact on vascular diseases. J Headache Pain. 2012 Apr; 13(3): 177–189.
Hansen J M, Lipton R B, Dodick D W. Migraine headache is present in the aura phase A prospective study. Neurology. 2012 Nov 13; 79(20): 2044–2049.
Narain S, Al-Khoury L, and Chang E. Resolution of chronic migraine headaches with intrathecal ziconotide: a case report. J Pain Res. 2015; 8: 603–606.
Eur J Phys Rehabil Med. 2009 Mar;45(1):61-7 and baclofen provide pain relief in seven patients with neuropathic pain and spasticity: case reports.
Saulino M, Burton AW, Danyo DA, et al. Intrathecal ziconotide Sacco S, Ricci S, Degan D, and Carolei A. Migraine in women: the role of hormones and their impact on vascular diseases. J Headache Pain. 2012 Apr; 13(3): 177–189.