Sequential administration of peripheral nerve blocks and onabotulinumtoxinA for the treatment of chronic migraine and other headache disorders-A retrospective tolerability and safety study.

OBJECTIVE: To determine the tolerability and safety of concurrent peripheral nerve blocks and onabotulinumtoxinA treatment during a single outpatient clinic procedure visit. BACKGROUND: Procedural interventions are available for the treatment of headache disorders. OnabotulinumtoxinA and peripheral nerve blocks are used as alternatives or in addition to oral therapies to reduce the frequency and intensity of migraine attacks. There is currently a lack of safety data focusing on the sequential administration of local anesthetic via peripheral nerve blocks and onabotulinumtoxinA during a single clinical encounter for the treatment of headache. The primary aim of the study was to determine the safety and tolerability of concurrent peripheral nerve blockade and onabotulinumtoxinA injections during a single outpatient clinic procedure visit. We hypothesized that the dual intervention would be safe and well tolerated by patients with chronic migraine and other headache disorders. METHODS: A retrospective chart review was performed using clinical data from patients seen by multiple providers over a 16-month timeframe at one outpatient headache clinic. Patients were identified by procedure codes and those receiving peripheral nerve block(s) and onabotulinumtoxinA injections during a single encounter within the study period were eligible for inclusion. Inclusion criteria were (1) patients 18 years and older who were (2) receiving both peripheral nerve blocks and onabotulinumtoxinA injections for the treatment of chronic migraine. Patients were excluded if they were under age 18, received their procedure outside of the clinic (emergency room, inpatient ward), or were receiving sphenopalatine ganglion blocks. Age- and sex-matched patients who received one procedure, either peripheral nerve blocks or onabotulinumtoxinA, were used for control. The primary outcome of this safety study was the number of adverse events that occurred in the dual intervention group compared to the single intervention control arms. Information regarding adverse events was gathered via retrospective chart review. If an adverse event was recorded, it was then graded by the reviewer utilizing the Common Terminology Criteria for Adverse Events ranging from Grade 1 Mild Event to Grade 5 Death. Additionally, it was noted whether the adverse event led to treatment discontinuation. RESULTS: In total, 375 patients were considered eligible for inclusion in the study. After age and sex matching of controls, 131 patients receiving dual intervention were able to be compared to 131 patients receiving onabotulinumtoxinA alone and 104 patients receiving dual intervention were able to be compared to 104 patients receiving peripheral nerve block(s) alone. The primary endpoint analysis showed no significant difference in total adverse events between dual intervention compared to nerve blocks alone or onabotulinumtoxinA alone. The number of adverse events that led to treatment discontinuation approached but did not reach statistical significance for those receiving dual intervention versus onabotulinumtoxinA alone in the number of adverse events that led to treatment termination (4.6%, 6/131 vs. 0.8%, 1/131, p = 0.065); however, the number of patients who discontinued therapy was not significantly different between those groups (2.3%, 3/131 vs. 0.8%, 1/131; p = 0.314; odds ratio 0.3 [0-3.2]; p = 0.338). CONCLUSIONS: In this retrospective chart review, there was no significant difference in adverse events or therapy discontinuation between patients receiving sequential peripheral nerve block(s) and onabotulinumtoxinA injections versus those receiving either peripheral nerve block(s) or onabotulinumtoxinA injections alone. As a result, we concluded that the combination procedure is likely safe and well tolerated in routine clinical practice.

Blood pressure elevation in erenumab-treated patients with migraine: A retrospective real-world experience.

BACKGROUND: Erenumab is a monoclonal antibody that targets the calcitonin gene-related peptide (CGRP) receptor and is approved for the preventative treatment of migraine in adults. CGRP is involved in the regulation of vasomotor tone under physiologic and pathologic conditions, including hypertension. While there has not been evidence of hypertension in preclinical models or clinical trials, post-marketing data suggest erenumab may be associated with hypertension. This led to a warning in the United States Food and Drug Administration prescribing information for erenumab. OBJECTIVE: To determine the frequency of worsening blood pressure (BP) after initiation of erenumab in patients with migraine and how this is associated with hypertension. METHODS: This is an observational retrospective cohort study evaluating patients at a tertiary headache or neurology department. Systolic and diastolic BPs were compared between the initial visit prior to initiation of erenumab, and follow-up visit while on erenumab. Worsening BP was defined as moving from a lower stage to a higher stage of BP, as defined by the American Heart Association. Serious adverse vascular events were also recorded. RESULTS: A total of 335 patients were included in the final analysis (mean [SD] age of 45.7 [14.40] years, 83.9% [281/335] female). At baseline, 20.9% (70/335) of patients had a prior diagnosis of hypertension. The median (interquartile range) time to follow-up appointment from initial appointment was 20.5 (13.3-35.3) weeks. The mean (SD) BP at baseline was systolic 124.7 (15) mmHg and diastolic 77 (11) mmHg, and at follow-up was systolic 124.0 (15) mmHg and diastolic 77.8 (9) mmHg. Overall, 23.3% (78/335) of all patients had worsening BP, whereas 13/225 (3.9%) patients had improvement in their BP. Patients with atrial fibrillation were more likely to develop worsening BP (odds ratio, 4.9, 95% confidence interval 1.12-21.4; p = 0.035). There was no association between worsening BP and pre-existing hypertension, sex, body mass index, or age. One patient had non-ST elevation myocardial infarction attributed to a hypertensive emergency while on erenumab. CONCLUSION: We found that 23.3% of patients initiated on erenumab may have developed worsening BP, suggesting the need for BP monitoring in patients initiated on erenumab.

Headache and Autonomic Dysfunction: a Review.

PURPOSE OF REVIEW: We explore the anatomy of the central and peripheral autonomic pathways involved in primary headache as well as the mechanisms for secondary headache associated with disorders of the autonomic nervous system. The prevalence and clinical presentation of cranial and systemic autonomic symptoms in these conditions will be discussed, with a focus on recent studies. RECENT FINDINGS: Several small studies have utilized the relationship between headache and the autonomic nervous system to identify potential biomarkers to aid in diagnosis of migraine and cluster headache. Headache in postural orthostatic tachycardia syndrome (POTS) has also been further characterized, particularly in its association with orthostatic headache and spontaneous intracranial hypotension (SIH). This review examines the pathophysiology of primary and secondary headache disorders in the context of the autonomic nervous system. Mechanisms of headache associated with systemic autonomic disorders are also reviewed.

Criteria for Emergency Brain MRI During Stroke-Alert.

OBJECTIVES: Intravenous (IV) tissue plasminogen activator (tPA) should be given to patients with acute ischemic stroke (AIS) and avoided in stroke mimics (SM). Select use of emergency brain magnetic resonance imaging (eMRI-brain) in stroke-alerts aids diagnosis, but accepted utilization criteria for eMRI-brain do not currently exist. We developed criteria for eMRI-brain and report the yield of eMRI-brain in stroke-alert patients. MATERIALS AND METHODS: We developed three history-based criteria for performing eMRI-brain during stroke-alerts: (1) history of previous similar deficits, (2) change in consciousness at onset of symptoms, (3) symptom presentation consistent with migraine aura. We then performed a retrospective chart review of patients who presented as a stroke-alert over a 5-year period and determined how these criteria affected administration of IV tPA to AIS and SM patients. RESULTS: Among 3,512 stroke-alerts, 230 (8.1%) patients met our criteria for eMRI-brain exams: 217 (92.6%) had SM and 17 (7.4%) had AIS. Our IV tPA decision-making analysis showed that based on eMRI-brain IV tPA was less frequently administered to SM patients (PCC-0.841, p=0.036) with less failures to administer IV tPA to patients with AIS (PCC -0.907, p-value=0.013, Pearson correlation coefficient). No patients became ineligible for IV tPA due to MRI-related time delays. CONCLUSIONS: Our history based criteria for performing eMRI-brain during stroke-alerts show a high yield of stroke mimics. Selective eMRI-brain improves decision-making accuracy regarding IV tPA administration.

Treatment of pediatric trigeminal neuralgia with microvascular decompression: a case series and systematic review.

OBJECTIVE: Trigeminal neuralgia (TN) is a rare disorder, affecting 4-13 per 100,000 people annually. Only 1%-1.5% of these cases are reported before the age of 18 years. The initial management of pediatric TN is based on symptomatic treatment, using first-line medications including carbamazepine, based on data from adult treatment studies. Many of these children are refractory to medication and undergo excessive workup and ineffective therapies before neurosurgical referral. The objective of this study was to perform a comprehensive review of literature-reported pediatric-onset TN, analyzing demographics, diagnostic practices, and complications in this population. METHODS: An institutional, retrospective chart review was performed to identify patients younger than 18 years old who were diagnosed with classic TN and referred for surgical evaluation at Oklahoma Children's Hospital (OCH). A systematic review of all pediatric patients undergoing microvascular decompression (MVD) for pediatric-onset TN was also performed. RESULTS: Three patients from OCH were identified, ranging in age from 3 to 11 years. All 3 patients had received multiple ineffective medical therapies before referral for neurosurgical evaluation. In 2 cases, imaging demonstrated potential vascular compression of the trigeminal nerve. In the final case, imaging demonstrated no vascular compression, but compression was found at the time of MVD. All cases were successfully treated using MVD. The literature review identified 49 cases of pediatric TN treated using MVD. All 49 cases were identified as classic TN with neurovascular compression demonstrated either on imaging or found at the time of surgery. The average age at symptom onset was 11.72 years, while the average age at MVD was 19.6 years. The average duration of symptoms before undergoing MVD was 8.2 years. There was a female predominance in the literature review, with a female-to-male ratio of 1.88:1. The right side was involved in 56% of cases, the left side in 40%, and bilateral involvement occurred in 4% of cases. The most common distribution of TN was both V2/3 branches (38%) of the trigeminal nerve, followed by solely the V2 branch (22%). A successful outcome (Barrow Neurological Institute pain intensity score of I or II) was reported in 79% of patients at the last follow-up (mean 69.1 months). CONCLUSIONS: There are currently no guidelines for diagnosing or treating pediatric TN. MVD is a safe and effective option in this patient population. Early evaluation for surgical intervention could be critical for early pain relief and reduced disease morbidity.

Cost-Effectiveness of Emergent MRI during Stroke Alert to Diagnose Stroke Mimics: Single-Center Experience.

Objective The aim of this article was to assess the role of emergent magnetic resonance imaging (MRI) for stroke mimics during a stoke alert (within 45 minutes) in reducing direct cost of management and duration of inpatient stay. Methods We did a retrospective chart review of all the patients who received emergent MRI brain during a stroke alert to help make decision about intravenous tissue-type plasminogen activator (IV tPA) administration from January 2013 to December 2015. Using the patient financial resource data and with the help of billing department, we calculated the approximate money saved in taking care of the patients who may have received IV tPA if emergent MRI brain was not available to diagnose stroke mimics as they presented with acute neurologic deficit within IV tPA time window. Results Ninety seven out of 1,104 stroke alert patients received emergent MRI. Of these only 17 (17.5%) were diagnosed with acute ischemic stroke (AIS), and 80 (82.5%) as stroke mimics. By doing emergent MRI for suspected stroke mimics, our study showed an approximate total saving of $1,005,720 to $1,384,560, that is, $12,571 to $17,307 per patient in medical expenditure. Discussion We suggest modification of stroke pathway from current algorithm "CT+CTA≥IV-tPA/neurointervention≥MRI" to "MRI+MRA≥IV-tPA/neurointervention" for possible stroke mimics, which can reduce the cost, radiation exposure, and duration of hospital stay for stroke mimics. Conclusion Emergent MRI is a cost-effective tool to evaluate IV-tPA eligibility for suspected stroke mimics during a stroke alert.

Endoscopic Endonasal Infrapetrous Transpterygoid Approach to the Petroclival Junction for Petrous Apex Chondrosarcoma: Technical Report.

Chondrosarcomas of the skull base are rare tumors that present difficult management considerations due to the pathoanatomical relationships of the tumor to adjacent structures. We present the case of a 25-year-old female patient presenting with a chondrosarcoma of the right petrous apex extending inferiorly, medial to the cranial nerves. The tumor was resected via an endoscopic endonasal infrapetrous transpterygoid approach that achieved complete resection and an excellent long-term outcome with no complications. Technical nuances and potential pitfalls of the case are discussed in depth including measures to protect the carotid artery while performing the required drilling of the skull base to access the lesion.