Headaches are almost ubiquitous. You talk to your neighbors or family members and, more than likely, almost one quarter of them will have migraine headaches. These severe headaches are bad enough, but some people even have chronic migraines, which are defined by the International Headache Society as fifteen or more headache days per month. Any less than that and you have episodic migraines. Potentially even worse are refractory chronic migraines, where traditional treatments do not seem to help. Many people have migraines or know someone who does and the impact can be significant.
- To put the far reaching effects of migraines into some perspective, here are some facts from the Migraine Research Foundation.
- Nearly 25% of households in the US have someone who suffers from migraines.
- In the United States, 18% of women, 6% of men, and 10% of children have migraines.
- If you have family members with migraines, then you’re at higher risk to develop the same. About 90% of people with migraines have other family members with migraines as well.
- According to this foundation, someone goes to the emergency department with head pain every ten seconds.
More than four million people suffer from chronic migraines.
- To add to the injury, more than 90% of migraine sufferers cannot function normally during acute attacks. Migraines can last between 4 and 72 hours. I have even seen some patients where the severe pain lasts for days.
- About 25% of people will also have associated visual disturbances called auras. Also, about 15-20% of people will have other neurological symptoms associated with the migraines called complex migraines. This can be anything from numbness, weakness, etc.
- Over 20% of chronic migraine sufferers are considered disabled. The cost of migraines in the United States every year is estimated to be approximately $36 billion dollars. Over
157 million work days are missed every year due to migraines.
- Especially with chronic migraines, the sufferers can develop other associated issues, including depression, anxiety, and sleep problems.
There are a lot of options for treatment that are available through your doctor and elsewhere, including medications such as topiramate or propranolol, botox injections, meditation, exercise, sleep hygiene, diet control, etc. However, the available treatments are at times not enough, unfortunately. This is where more research is needed. There has been a resurgence of academic interest in ketamine infusions for pain, and migraines specifically.
A study published in the journal Headache in 2017, titled Ketamine Infusions for Treatment Refractory Headache, looked into ketamine infusions for treatment of refractory headaches. They evaluated 77 patients with chronic migraines or new daily persistent headaches who had failed previous aggressive treatments. They used a pain scale of 0 to 10 with 10 being most severe. On admission, the trial participants averaged 7.1. On discharge from the hospital, they averaged 3.8. Over 71% of patients were acute responders where they showed at least a 2 point improvement on the 0 to 10 scale. Over 27% of these acute responders maintained this benefit at their subsequent outpatient office visit. The average length of hospital stay was just under 5 days and most patients tolerated the ketamine infusions well. They concluded that subanesthetic ketamine intravenous infusions may help patients with chronic migraines or new daily persistent headaches who have failed other treatments.
Ketamine for Refractory Headache
A different study published in BMJ in 2018, titled Ketamine for Refractory Headache: A Retrospective Analysis, further researched ketamine intravenous therapy for refractory headaches. Over three years, they looked at 61 patients admitted for five days of continuous ketamine intravenous therapy. Approximately 77% of the 61 patients were immediate responders, defined as an improvement in the 0 to 10 pain rating scale of two points or more while in the hospital. The ultimate improvement was seen at a mean of 4.56 days while admitted. Approximately 44% of those responders had a sustained response after a mean of 38.1 days, and about 39% of those responders had a sustained response even after a mean of 101.3 days. A sustained response was met when the patients maintained that two point improvement at the follow up visits. The maximum ketamine rate during this study was 0.76 mg per kg per hour. They concluded that ketamine intravenous infusions were associated with short-term improvement in many refractory headache patients with mild side effects.
Ketamine for Refractory Chronic Migraine
A third study is currently enrolling. It is called Ketamine for Refractory Chronic Migraine: a Pilot Study, and is sponsored by Thomas Jefferson University. In this study, patients with refractory chronic migraine who fail treatment at a different hospital will be admitted for five days to their neurology team, and their acute pain anesthesia service will manage the ketamine intravenous infusions. Exclusion criteria are consistent with the 2018 Consensus Guidelines for Ketamine, including schizophrenia, active psychosis, pregnancy, poorly controlled cardiovascular disease, cirrhosis, and previous intravenous ketamine treatment. They will monitor patients using 0 to 10 numerical pain rating scale, 0 to 3 qualitative pain rating scale (0=none, 1=mild, 2=moderate, 3=severe), headache diary, and depression screening. In addition, they will be checking blood levels of ketamine metabolites, such as norketamine, hydroxynorketamine, hydroxyketamine, and dehydroxyketamine, at times 0 hr, 24 hr, 48 hr, 72 hr, and just before the end of the infusion to correlate these levels with response to treatment. Follow up visits will then be after 2 weeks and 2 months following discharge from the hospital. The official start date for this study was March 22, 2019, and the estimated study completion date will be March 2021.
As a neurologist, I see headaches every day in my practice. These studies provide new hope for my headache patients and everyone else suffering from chronic migraines or daily persistent headaches. Sometimes, the treatments we currently have available do work. I frequently use amitriptyline, topiramate, or propranolol as prophylactic headache medications in my neurology practice. The new class of CGRP antagonists are opening new avenues for potential treatment for patients who have gone too long without success. However, no one treatment works for everyone. Everyone’s body chemistry is different. All too often, unfortunately, I find myself using one medication after another with either no improvement or a debilitating adverse effect. This is where new treatments are desperately needed. If you suffer from refractory migraines, then you know the frustration and suffering that goes along with it. Ketamine may work for certain patients, and it is great to have another option with good evidence with apparently only mild adverse effects. More research is needed but this opens up more possibilities for success.
At RevIVe Wellness, we are a team of neurologists, anesthesiologists, and functional medicine physicians who bring a comprehensive and individualized approach to headache and migraine treatment. As stated in our other blog Headaches: Don’t Suffer in Silence, you need to treat the whole body while treating the headache, or sometimes even before. If you have already been on a merry-go-round of medications or do not want to take that unfortunate ride, consider the whole body approach to wellness and headache treatment. This will potentially include dietary changes, IV vitamin/hydration supplementation, exercise, GI management, and sleep hygiene. Now that we have evidence that supports the potential use of IV ketamine infusions for the treatment of refractory chronic migraines and daily persistent headaches, it increases our chances of success.