Is propofol the new wonder drug for treating headaches?
You know the scenario: a patient comes in with headache for the previous few hours or even days. It’s the same as the patient’s normal migraine, but very severe and won’t go away. What do you do? A bit aspalgin and/or codeine and/or fluid and/or metoclopramide. In many cases you reach for the ‘largactil’, 25mg in a litre of saline and if your patients are like mine, you need another bag of the same. It’s now 2-4 hours down the track and the patient is sleepy and just wants to go home. Sounds familiar?
Well, here is some published evidence for the use of ‘propofol’ in this scenario.
In a paper in 2000 [Headache, 2000, March; 40 : 224-230] Krusz, et. al. initially observed improvement of headache in patients treated with propofol in preparation for epidurals and other nerve blocks. They conducted a study of 77 patients with intractable headaches, both migrainous and non-migrainous in a pain clinic. The results were surprising to say the least. Headache intensity was reduced on average by 95.4% after 20-30 minutes. Sixty-three of the seventy seven patients had total resolution of their headache and only three patients had a return of headache the following day. The average dose of propofol was 110 mg, considered a sub-anaesthetic dose in this group.
Since then, there have been several case reports of the use of propofol for migraine headaches. In the latest case report [Anaesthesiology, February 2007, volume 106, issue 2, page 405-406] propofol was used in a patient with a two-week history of intractable migraine headache that had been complicated by severe hemicranial pain, photophobia and phonobia, and left eyelid droop. The patient has had multiple medications trial with no success. The patient had been admitted and a neurologist at the Anaesthethetics Department was to assist with a sub-anaesthetic dose of propofol.
A visual analogue scale was used to monitor pain. This is what happened:
Initial pain score was 6/10 with photophobia
20 mg of IV propofol was then given every five minutes to a maximum of 120 mgs over 30 minutes.
At five minutes: The pain score was 5/10.
At 20 minutes [80 mg]: The pain score was 2/10
At 30 minutes [120 mg]: The pain score was 0/10 and the photophobia resolved.
In the most recent study [BMC Neurology, 2012; 12] Soleimanpour, et. al. conducted a double blind, randomized trial of 90 adult patients who presented with migraine headache.
The patients were divided into two groups: Group 1 received IV propofol, Group 2 received IV dexamethasone.
The dose of propofol was 10 mg every 5-10 minutes to a total of 80 mg. The dose of dexamethasone was 0.15 mg/kg to 16 mg total.
The reduction in headache score in the propofol group (1.44±1.63) was significantly greater [P<0.05] than the dexamethazone group (3.06±2) at 30 minutes.
The propofol group had a more rapid result and there were no side effects.
Here is my take on this.
Safety comes first. Obviously, make sure that an airway trained person is available if we’re giving propofol to a patient. Make sure the monitoring is in place and all the airway equipment is there and checked and ready to go.
How much propofol would I give: Well I would probably start with 10 mg every five minutes for the first two doses, and then continue with 20 mg for the rest of the doses up to 30 minutes, five minutes apart, to a total of 100 mg. I would be very careful in monitoring blood pressures of the patient( beware in the very old). I am making sure that they would not be anaesthethized or that these are sub-anaesthetic doses.
Propofol for migraine… I’m going to give it a go. Let me know if you use it out there.