Background & Aims
New daily persistent headache (NDPH) is a primary headache disorder, which presents from the onset as a constant, persistent, daily headache. Along with pain, patients with NDPH often experience a variety of associated symptoms, including fatigue, nausea, mental fog, dizziness, and reduced tolerance for physical and mental activity. NDPH is found in all age groups but is most prevalent in adolescents. At present, there is not yet an indicated, evidence-based treatment for NDPH. Unfortunately, it appears refractory to most interventions, including preventative medications, rescue medications, and injection procedures. Since lidocaine infusions have proven to be effective in treating other types of chronic pain, it is hoped that headache pain from NDPH would also be responsive. The purpose of this investigation was to evaluate the tolerance to and effectiveness of short duration lidocaine via infusion for adolescents with NDPH.
Methods
Per clinic protocol, adolescent patients (N=55, M age = 16.2 years, 93% female) diagnosed with NDPH were administered a short-duration infusion of intravenous lidocaine, consisting of 200mg infused over two hours for those weighing more than 50kg (2 mg/kg for those weighing less than 50kg) in an outpatient hospital setting. Patients completed a questionnaire, via REDCap secure electronic platform, evaluating its safety and effectiveness at four time-points: immediately post-infusion (T1), one day post-infusion (T2), one week post-infusion (T3), and one month post-infusion (T4). Safety was measured via self-reported mild and severe side effects. Effectiveness was measured via self-reported numeric pain scores, headache frequency, associated symptoms, and functioning. Repeated measures ANOVAs (with follow-up paired-samples T-tests) were used to assess changes in all continuous variables over time; change in headache frequency was assessed via chi-square, as it was measured categorically.
Results
With regard to safety, about one third of patients (37%) reported at least one mild side effect immediately after lidocaine infusion (T1). However, only 6.7% reported mild side effects at T2, and no patients reported any mild side effects at T3 or T4. These decreases were statistically significant. Further, no patients reported severe side effects at any study timepoint. With regard to effectiveness, RMANOVAs were underpowered to detect change over all four timepoints, due to missing data. However, paired-samples t-tests revealed significant decreases in headache pain severity, decreases in associated symptoms, and increases in mental/physical functioning from T1 to T3 and from T1 to T4. Chi-square results indicated a significant decrease in headache frequency, with more patients than expected transitioning from daily headaches to episodic (or no) headaches.
Conclusions
While not all patients experienced a decrease in headache pain itself, most reported improvements in associated symptoms and in functioning, which were significant and sustained for at least one month. Anecdotally, patients expressed that they could tolerate having a persistent headache when they experienced fewer associated symptoms and could engage in daily mental and physical activity. For patients with few effective treatment options, short duration lidocaine infusions could represent some hope for improvement in headache, overall functioning, and quality of life for adolescents with NDPH. This promising intervention offers another tool in treating this difficult headache condition.
References
Akbar, A., 2017. Response of refractory new daily persistent headache to intravenous lidocaine treatment in a pediatric patient. J Pain Relief, 6(4).
Berk, T. and Silberstein, S.D., 2018. The use and method of action of intravenous lidocaine and its metabolite in headache disorders. Headache: The Journal of Head and Face Pain, 58(5), pp.783-789.
Marmura, M., Rosen, N., Abbas, M. and Silberstein, S., 2009. Intravenous lidocaine in the treatment of refractory headache: a retrospective case series. Headache: The Journal of Head and Face Pain, 49(2), pp.286-291.
Yamani, N. and Olesen, J., 2019. New daily persistent headache: a systematic review on an enigmatic disorder. The journal of headache and pain, 20, pp.1-9.
Presenting Author
Victoria Karian
Poster Authors
Topics
- Specific Pain Conditions/Pain in Specific Populations: Headache