A case report of Migraine Headache Treated with Famciclovir and Celecoxib
A healthy 21-year-old white female college student with a visual aura consisting of scintillating scotoma followed by headache onset was presented for treatment. A headache was reported to be severe and throbbing in nature with nausea and mild confusion. She was advised to take NSAIDs during this time. There was no improvement in her symptoms, and a neurologist was consulted, and she was diagnosed with an acute migraine headache. Various nonspecific hyperintensities in the pericortical frontal lobe on T2-weighted images were revealed after an MRI scan with the exclusion of possibilities of stroke, multiple sclerosis, or other neurologic disorders.
What will be the most effective treatment for a migraine headache in this case?
- Ganglioside analog such as Famciclovir
- Combination of Cyclooxygenase-2 inhibitors (Celecoxib) and Ganglioside analog (Famciclovir)
The pathophysiology of a migraine headache has not been fully elucidated yet. Previous studies have indicated the role of various genetic, chemical, and anatomic factors in the occurrence of migraine. Researchers have observed that a migraine is partially heritable and tends to move from families to families (1). Others describe activation of the trigeminovascular system, cortical spreading depression, and neuronal sensitisation as physical phenomena leading to a migraine (2). It was also evaluated that a triggering event in a genetically predisposed patient can initiate a cascade resulting in the headache experience. Peculiarly, activation of trigeminal ganglion was the most common and early observation among patients with migraine (1). The occurrence of herpes simplex virus (HSV) along with trigeminal ganglion, also plays a role in migraine headache pathophysiology (3). So, the treatment strategy includes targeting HSV infection that can play an integral part in the management of a migraine headache.
Medical History and Examination
The patient has a medical history of visual aura consisting of the scintillating scotoma. She experienced a severe headache with throbbing pain, nausea and vomiting. She was advised to take NSAIDS. The possibilities of stroke, multiple sclerosis, and other neurological disorders were excluded. The patient had no medical history of cold sores. The patient began a trial of several migraine headache treatments, including triptans, beta blockers, prednisone, and injections of botulinum toxin. She reported difficulty in cognitive functions, especially concentration. She had experienced trouble in her college coursework and had to take an excused absence for the semester. Her sleep quality also deteriorated significantly.
After seven months of initial presentation, the patient was advised by the physician to take famciclovir and celecoxib. She demonstrated symptomatic relief within five days and also indicated an improvement in sleep quality. She was able to return to her college course load while taking maintenance doses of famciclovir and celecoxib. After three years after the onset of symptoms and 15 months after starting famciclovir and celecoxib therapy, she experienced a remarkable reduction in the severity and frequency of migraine symptoms. It helped her to complete her undergraduate coursework and to work fulltime without interruption. After 12 months of treatment, her treatment was discontinued as there was no incidence of severity or frequency of symptoms.
A migraine is a severe headache disorder associated with physical, psychological, and financial morbidity (5). It affects approximately 15% of the general population in the US (4). It accounts for an average of 8.3 days of absenteeism and 11.2 days of reduced productivity per affected individual each year, with an overall estimated cost to employers of $3309 per affected employee (4). The management modalities consist of acute abortive pharmacotherapies, prophylactic pharmacotherapies, and adjunctive therapies. Acute abortive pharmacotherapies constitute use of nonsteroidal anti-inflammatory medications, acetaminophen, glucocorticoids, opioids, triptans, and ergots. Prophylactic pharmacotherapies include beta blockers, calcium channel blockers, tricyclic antidepressants, selective norepinephrine reuptake inhibitors, and antiepileptic medications, whereas adjunctive therapies constitute acupuncture, biofeedback, massage therapies, and onabotulinumtoxin-A injections (6).
There has been much supposition about the correlation between migraine headaches and HSV, which has been implicated in a few forms of cranial nerve (CN) disorders. HSV infection is commonly managed with a ganglioside analog medication. Famciclovir is an example of one such drug that belongs to this class of drugs. Another type of drugs that can be used for management of HSV infection is cyclooxygenase-2 inhibitors such as celecoxib. A synergy between famciclovir and celecoxib in treating HSV infection has been proposed and studied (7). Another phase 2A randomised study of chronic fatigue syndrome has evaluated the efficacy of famciclovir in conjunction with celecoxib and demonstrated a twofold to threefold symptom improvement in patients treated with famciclovir and celecoxib when compared with placebo (8).
This case indicates a substantial improvement in migraine headache symptoms with the use of famciclovir and celecoxib (both medications with direct antiviral activity toward HSV). The combination of drugs was used with definite effect, initially as an abortive therapy and then as prophylactic therapy. These medications might work in conjunction to treat migraine disorders by the current understanding of the pathophysiology of migraine headaches, precisely the role of HSV-mediated trigeminal inflammation in migraine symptomatology and the antiviral characteristics of famciclovir and celecoxib. It was also hypothesised that migraine might be attributable to a reactivation of a latent HSV residing within the trigeminal ganglion, but still, there is need of further prospective trials using famciclovir and celecoxib to elucidate the respective role each may play in treating migraine disorder.
- Cutrer FM. Pathophysiology of migraine. Semin Neurol. 2010 Apr;30(2):120–30.
- Charles A. Advances in the basic and clinical science of a migraine. Ann Neurol. 2009 May;65(5):491–8.
- VanElzakker MB. Chronic fatigue syndrome from vagus nerve infection: A psychoneuroimmunological hypothesis. Med Hypotheses. 2013 Sep;81(3):414–23.
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- Gebhardt BM, Varnell ED, Kaufman HE. Inhibition of cyclooxygenase 2 synthesis suppresses herpes simplex virus type 1 reactivation. J Ocul Pharmacol Ther. 2005 Apr;21(2):114–20.
- Pridgen WL, Duffy C, Gendreau JF, Gendreau RM. A famciclovir + celecoxib combination treatment is safe and efficacious in the treatment of fibromyalgia. J Pain Res. 2017 Feb 22;10:451–60.