Prolotherapy in the treatment of chronic migraine — Case report

Abstract


Introduction
Chronic migraine is a socioeconomic and individual burden since it is the largest cause of disability in people under 50 years of age.Although there are several prophylactic drug alternatives, some patients are vulnerable to refractoriness with significant damage to their quality of life.Prolotherapy, a subcutaneous injection of dextrose in peripheral nerves, advocates as a promising tool in the management of this pathology.Case report A patient with refractory chronic migraine to drug therapy who was submitted to neurofascial prolotherapy.Weekly administration of a 2 ml solution of 1% ropivacaine and 10% glucose in the head peripheral nerves for 6 weeks.Reduced disability and frequency of migraine attacks for a period of 8 weeks after interventions.

Conclusion
Prolotherapy proved itself to be a notable technique for reducing the number of days in a month that a patient with refractory chronic migraine to standardized therapy has had headaches.However, placebo group studies are needed to determine the efficacy of the procedure.

Introduction
3][4][5] Therefore, it is important to seek useful therapeutic strategies to avoid recurrence and impairments linked to migraine attacks when conventional prophylactic treatment does not generate good results.
In different degrees of evidence, the drug groups used in chronic migraine prophylaxis involve antidepressants, antiepileptics, antihypertensives and calcitonin generelated peptide (CGRP) antagonists.As for the minimally invasive intervention, there are prolotherapy and botulinum toxin type A. 6 Neurofascial prolotherapy is a technique developed by Lyftogt that consists of the perineural injection of 5% dextrose diluted in sterile water into subcutaneous nerves 7 and has proved to be a promising option for the treatment of chronic migraine, when admitted that this condition comes from an introduced sensitization of pain pathways into the central nervous system. 8While dextrose acts with significant long-term analgesic and antiinflammatory potential, the local anesthetic, ropivacaine, can alter the activity of pain pathways, blocking them instantly. 7This can ensure better adherence of the patient to treatment due to the less traumatic pain experience after the procedure.
The objective of this study is to report the case of a patient with refractory chronic migraine to drug therapy who was submitted to prolotherapy in a pain-specialized center.

Case report
A 25-year-old woman presents a history of persistent and disabling headache for 3 years.Constant and daily headache attacks with severe intensity and the presence of nausea, vomiting, photophobia and phonophobia.Without aura.Signs of pain worsening during physical activities.Reports previous use of venlafaxine (300 mg/ day), topiramate (200 mg/day), and chlorpromazine, as well as frequent use of anti-inflammatory agents, corticosteroids, and triptans.Even during optimized drug therapy, intense pain remained.Neurological examination showed no focal alterations and unaltered neuroimaging.Patient without previous comorbidities.The patient was submitted to an anesthetic scalp block with serial ropivacaine and glucose for six consecutive weeks.In this period, a standardized application of a 2 ml solution composed of 1% ropivacaine and 10% glucose was performed, distributed in the points listed in Figure 1.The improvement of the general pain, with control of migraine attacks and improvement of disability was reported by the patient over the course of 8 weeks.In the follow-up appointment, the patient maintained control of symptoms and did not present complications due to the procedure.

Discussion
Although little elucidated, evidence points to a selfpropagating wave of neuronal and glial depolarization in the cerebral cortex that triggers a prolonged trigeminal nociceptive activation, responsible for establishing a sterile meningeal inflammation that determines migraine pain. 8,9,10This neurogenic inflammation releases a series of important peptides for the prolongation and intensification of migraine 11,12, among which stands out the operation of inflammatory mediators as agonists of the transient receptor potential vanilloid subtype 1 (TRPV1), substance P and CGRP. 13,14,15olotherapy is a minimally invasive application procedure of a solution composed of 5% dextrose and sterile water in subcutaneous nerves 6 , whose principle is the blocking effect of dextrose on the capsaicin TRPV1 receptor that establishes a sensorineural inflammatory cascade responsible for pain when activated. 13,16,17Regarding this mediator, the study by Simone et al. 18 detected a logic between the capsaicin TRPV1 agonism and hyperalgesic response to mechanical stimuli and heat. 14When activated, this receptor transmits a sensory stimulus through calcium and sodium influx, translated into the brain as a burning, stinging or itching sensation.This suggests that the TRPV1 antagonism made by dextrose neural prolotherapy can, at least in part, act by obliterating the inflammatory storm in the functional mechanism of migraine.This may be the reason why the improvement of the pain and associated symptoms in the reported patient submitted to neurofascial prolotherapy could be noticed.This understanding is particularly important because it outlines new roadmaps in migraine management, especially in cases resistant to the standardized approach, such as this one.
In addition, ropivacaine is a long-acting local anesthetic with less toxic potential than other equivalent anesthetic solutions, which demonstrates its efficacy and safety for anesthesia and analgesia in peripheral nerve block, both in single application and in continuous peripheral blocks.When combined with dextrose, it produces a long-term analgesic response in a short time, providing the patient with an instantaneous analgesic experience after the procedure. 19e main limitation of this report is the impossibility of assigning an evident cause value to the proposed intervention, since there was no review of the intervention by control group, nor collected and analyzed longitudinal variables (such as dietary or physical activity modifications).

Conclusion
Prolotherapy proved itself to be a promising adjunct for the treatment and control of migraine attacks.A minimally invasive option for the control of refractory pain to conventional treatments.Applying this technique to the treatment of migraine, we obtained excellent results in pain control.It is noteworthy that the effective technique depends on an operator with experience and vast knowledge of the procedure, anatomy and medical history of the patient, since the indication comes from resistance to traditional methods.
The dissemination of the technique through documentation and publications on the application mechanism and the obtained results promotes the expansion and improvement of access to new treatment methods for headache.Thus, the evolution of prolotherapy allows new patients to be able to return to daily activities, without impairment or disabilities caused by chronic pain.Finally, more research with placebo group evaluations is necessary to expand the indications and improve the therapeutic regimens, to favor individuals with similar clinical conditions.