Headache Medicine, v.3, n.1, p.41-43, Jan./Feb./Mar. 2012 41

Intravenous lidocaine for inducing remission of

cluster period

Lidocaína intravenosa como indutor de remissão de surto de cefaleia

em salvas

ABSTRACTABSTRACT

ABSTRACT

Cluster headache is a rare clinical condition, classified by the

IHS as a trigeminal autonomic cephalalgia. Some known

abortive treatments are inhaled oxygen, subcutaneous

sumatriptan, intravenous dihydroergotamine and intranasal

lidocaine. However, previous case reports suggest that

intravenous lidocaine may play a role in the treatment of cluster

headache attacks. We describe a patient with refractory cluster

headache, whose condition remitted after the use of intravenous

lidocaine. Therapy with lidocaine was conducted without harm,

and the remission after a "single shot" suggested this approach

to be safe and desirable to be tried in patients with cluster

headache..

Keywords: Keywords:

Keywords: Intravenous lidocaine; Cluster headache

RESUMORESUMO

RESUMO

A cefaleia em salvas é uma rara condição clínica que faz parte

das cefaleias trigêmino-autonômicas. Há alguns tratamentos

abortivos descritos na literatura, como oxigênio inalatório,

sumatriptana subcutânea, dihidroergotamina e lidocaína

intranasal. Relatos de caso sugerem o uso da lidocaína intra-

venosa como terapêutica destas crises. Descrevemos um caso

de portador de cefaléia em salvas forma refratária, cuja condição

remitiu ao uso de lidocaína endovenosa. A resposta eviden-

ciada sugere que um tratamento do tipo "single shot" com

lidocaína endovenosa é seguro e desejável para os portadores

de cefaleia em salvas.

alavrasalavras

alavras

chave: chave:

chave: Lidocaína endovenosa; Cefaleia em salvas

CASE REPORTCASE REPORT

CASE REPORT

Paulo Sérgio Faro Santos

, Renato Endler Iachinski

, Henry Koiti Sato

, Maria Tereza Moraes Souza

Nascimento

, Ricardo Krause Martinez de Souza

, Vanessa Rizelio

, Pedro André Kowacs

Medical Student, Universidade Federal de Sergipe – UFS, Aracaju, SE, Brazil

Neurology Service, Instituto Neurológico de Curitiba, Curitiba, PR, Brazil

Santos PS, Iachinski RE, Sato HK, Nascimento MT, Souza RK, Rizelio V, et al.

Intravenous lidocaine for inducing remission of cluster period. Headache Medicine. 2012;3(1):41-3

INTRODUÇÃO

Cluster headache is an uncommon condition, most

prevalent in men and classified by the IHS as a trigeminal

autonomic cephalalgias, term originally coined by

Goadsby and Lipton, in 1997.

(1,2)

It is characterized by

attacks of headache (orbital, retro-orbital or temporal)

and are accompanied by autonomic symptoms, that last

from 30 to 180 minutes, at a frequency that ranges from

one crisis each other day up to eight crises per day during

the cluster period, frequently with a circadian periodicity

of the attacks, and a circannual periodicity of the cluster

periods.

(2)

Some therapies have been recommended for

treatment of cluster headache attacks, such as inhaled

oxygen, subcutaneous sumatriptan, intravenous dihydro-

ergotamine and intranasal lidocaine.

(3)

Intravenous

lidocaine was reported to be effective in the acute control

of attacks of SUNCT syndrome (Severe Unilateral

Neuralgiform Headache with Conjunctival Injection and

Tearing), another type of trigeminal autonomic

cephalalgia.

(4,5)

However, its use on the treatment of cluster

headache attacks was reported in a few papers, and

remains largely unknown.

(6,7)

We describe a case of a refractory cluster headache

patient, whose condition remitted after the use of

intravenous lidocaine.

42 Headache Medicine, v.3, n.1, p.41-43, Jan./Feb./Mar. 2012

SANTOS PS, IACHINSKI RE, SATO HK, NASCIMENTO MT, SOUZA RK, RIZELIO V, ET AL.

CASE REPORT

The patient was a 49 year-old male, who has been

suffering from cluster headache since the age of 37. The

intensity and frequency of his cluster headache attacks

had progressively worsened in the last seven years. There

was no history of remission periods exceeding 30 days in

the last year. At the time of his admission, he was using

topiramate 75 mg o.d. and naratriptan 2.5 mg b.i.d..

Twenty milliliters of lidocaine 2% diluted in 240 mL of

dextrose 0.5% were infused at 60 mL/h. During the infusion

the patient was kept under cardiac monitoring. There were

no adverse events. The patient had no headaches during

the infusion period, and remained cluster headache-free

at the follow-up, even after naratriptan withdrawal and

after reduction of topiramate to 25 mg 1 b.i.d.. Discussion

Lidocaine is a local anesthetic widely used in medical

practice for regional anesthesia in peripheral and central

neuropathic pain.

(8,9)

It can be administered by different

routes: epidural, spinal, intramuscular, intrapleural, topical,

intranasal and intravenous.

(8)

Intranasal lidocaine has been

used as adjuvant treatment for attacks of cluster headache

since 1985

(10)

and, similarly, was tried in the treatment of

migraine.

(11)

While success is achieved in addressing these

painful situations, this is not a usual practice.

(10-13)

In addition,

other studies show the use of intravenous lidocaine to abort

SUNCT attacks.

(4,5)

In 2004, Matharu

(5)

described four cases

of SUNCT patients who showed disappearance of the

headache during intravenous lidocaine administration.

However, recurrence was observed approximately 15 to

20 minutes upon termination of the infusion.

(5)

Adverse

events were reported by three patients and consisted of

nausea and vomiting, depressive symptoms and paranoid

ideation.

(5)

In two patients, SUNCT remitted for about a

year after the intravenous administration of lidocaine and

substitution of the previous prophylactic medications for

topiramate.

(5)

Arroyo, in a 2010 double-blind study

(4)

demonstrated that intravenous lidocaine was superior to

placebo in the treatment of SUNCT. These authors

reinforced the need for patient monitoring during the

intravenous administration of lidocaine.

(4,5)

Although the

results suggest a good response to intravenous lidocaine

as an abortive therapy of SUNCT, its mechanisms of

action are still unclear.

(4)

In 1988, Maciewicz

(6)

reported

the use of intravenous lidocaine for treating migraine and

cluster headache attacks. In this report, the author found

a significant reduction in pain intensity reported by patients

with cluster headache.

(6)

He also suggested that the good

result was due to the direct action of lidocaine in the

trigeminal nociceptive input from local blood vessels.

(6)

Marmura, in 2009,

(7)

through a retrospective study on the

use of intravenous lidocaine in 68 patients, two of whom

were suffering from cluster headache, reported a 50%

improvement of pain after administration of the anesthetic

in these patients. Just as in SUNCT, lidocaine mechanism

of action involved in termination of cluster headache attacks

is unclear.

(4,7)

However, Leone (2009)

(14

) suggested cluster

headache and SUNCT to share similar pathophysiological

mechanisms. This assumption is due to the presence of

hypothalamic activation in cluster headache and SUNCT

as well as the positive response of both conditions to high-

frequency hypothalamic stimulation.

(14)

As summed up by Lauretti (2008)

(9)

"the final

analgesic action of intravenous lidocaine reflects the

multifactorial aspect of its action, resulting from the

interaction with sodium channels, and direct or indirect

interaction with different receptors and nociceptive

transmission pathways such as muscarinic antagonism,

glycine inhibiton, reduction in the production of excitatory

amino acids, reduction in the production of thromboxane

A2, release of endogenous opioids, reduction in

neurokinins and release of adenosine triphosphate".

Finally, intravenous lidocaine was generally

considered to be safe in this setting of administration, and

may obviate the need for prolonged medical, semi-

invasive or invasive therapies. Based upon the "single-

shot" response observed in this case, prospective controlled

double-blind studies to prove the efficacy of intravenous

lidocaine in remission of symptoms of cluster headache

are desirable.

REFERENCES

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3. Cohen AS, Goadsby PJ. Prevention and treatment of cluster

headache. Prog Neurol Psychiatry. 2009;13(3):9-16.

4. Arroyo Am, Durán XR, Beldarrain MG, Pinedo A, García-Moncó

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Relief of vascular headache with intravenous lidocaine: clinical

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4:11-6.

Headache Medicine, v.3, n.1, p.41-43, Jan./Feb./Mar. 2012 43

INTRAVENOUS LIDOCAINE FOR INDUCING REMISSION OF CLUSTER PERIOD

Correspondence

edro André Kedro André K

edro André K

owacsowacs

owacs

Instituto de Neurologia de Curitiba

Rua Jeremias Maciel Perretto 300 – Bairro Ecoville

81210-310 – Curitiba, PR, Brazil

e-mail: pkowacs@gmail.com

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Received: 12/20/2011

Accepted: 1/22/2012