I’ve been waiting for some time now. Waiting, for the perfect patient with severe, unremitting migraine, unresponsive to all analgesia, to present, so I could use propofol as treatment.
A short time ago I wrote a blog titled ‘Is Propofol the New Wonder Drug for Headaches?’, where small doses of propofol(10-20mg) were give every 3-5 minutes, to maximum dosages of about 120mg, to patients with long-standing unremitting migraines, with good effect.
The perfect patient appeared recently. She was in her 60’s, with no other real history, except migraines. Her current migraine headache had been there for two weeks. Nothing could get rid of it. She had taken all of her normal medications, to no effect. She had escalated her analgesia, nothing. She was distraught and very upset. She was also fasted. Following an explanation of what was to be done, the patient agreed to proceed.
Perfect. What was amusing was the mixed response from staff towards me, for wanting to try this. Propofol for migraine, they had never heard of it. The response ranged from some people, I’m sure, thinking that I had no idea what I was doing, to those that were generally interested to see if it would work. The proof is in the pudding and soon there was a bit of interest in reading the blog article.
The patient was attached to monitoring and nasal prongs were applied with 2L of wall oxygen. The patient had a BP of 110 systolic and a pulse rate in the 80’s initially. The blood pressure was my only concern as the propofol could drop this further.
One Litre of normal saline was hung and the line opened. 20 mg aliquots of propofol were given, on average every 4 minutes and the blood pressure was checked and the patient’s pain score was also checked.
The blood pressure did drop and small doses of metaraminol were used to support this. At no time did the BP drop below 95mmHg systolic, nor was the patient symptomatic at any time. In fact, the patient had her eyes closed, but was able to converse with us at all times and relate what she was feeling.
With each dose the pain score reduced from the initial 10/10 to 1/10 following a total of 120mg of proposal. In fact, following the first dose, the pain dropped from 10 to 8 and the patient was markedly relaxed.
The propofol was then ceased and the patient allowed to rest. The pain score did increase by a small amount during the rest period, however, the improvement was vast and following a period of observation, the patient went home.
Take home points are:
1 I should have given a little more proposal , i.e.., made my endpoint total relief of headache.
2 It goes without saying that an airway trained doctor is required for this and the patient should be fasted.
3 The downside of this technique, is that it takes a senior person away for 20-30 minutes.
4 The upside is that the patient can go home following a brief observation period, because they have been awake throughout the whole thing. This means, nobody in a bed for a few hours , with fluids and ‘largactil’ and in many cases, a persistent significant headache following treatment.
I know that my experience with this one case was so favourable, that it is a technique, that, time permitting, I would use again.