To the Editor:—
A small number of open-label trials1,2
and case reports3,4
support the use of intravenous propofol in subanesthetic doses for the management of chronic severe intractable migraine headache. The largest of these, which included 77 patients, reported an average reduction in headache intensity of 95.4%. In this study, 63 of 77 patients reported complete resolution of headache symptoms after receiving 120 mg of propofol delivered over 30 min.
We report the case of a 54-yr-old woman who was admitted to the hospital with 2 weeks of severe, intractable migraine headache, complicated by severe hemicranial pain, photophobia, phonophobia, and a new left eyelid droop. After completing a full neurologic work-up, which was negative, the patient was diagnosed with status migrainous. Multiple medications, including gabapentin, pregabalin, sumatriptan, carisoprodol, promethazine, ketorolac tromethamine, and morphine sulfate, were all attempted with limited success.
Our anesthesiology service was consulted by the patient’s neurologist for a subanesthetic trial of propofol, as reported by Krusz et al
On the visual analog scale of 0-10, the patient reported a score of 6 for frontal head-pain and experienced significant photophobia just before the injection of propofol. She then received 20 mg IV every 5 min to a maximum of 120 mg over 30 min. Within 5 min, the patient’s pain scale score decreased to 5. By 20 min (80 mg), she reported a score of 2 and stated that she could not remember the last time she felt this good. By 30 min (120 mg), she reported a pain score of 0 and commented that she could remove her dark glasses without any photophobia and that her headache was gone. Five hours later, and after 5 days in the hospital, the patient was discharged home without pain.
Although existing studies are small, this case report, in conjunction with smaller studies reported elsewhere, supports the use of propofol in subanesthetic doses for the treatment of severe migraine headache. These observations also suggest the involvement of the γ-aminobutyric acid type A receptor in the etiology of migraine headaches. It seems that a large-scale trial to examine the efficacy of propofol, at least for acute headache control, is warranted.
Joshua Aaron Bloomstone, M.D.
Valley Anesthesiology Consultants, Ltd, Phoenix, Arizona. firstname.lastname@example.org
1. Krusz JC, Scott V, Belanger J: Intravenous propofol: Unique effectiveness in treating intractable migraine. Headache 2000 Mar;40:224–30.
2. Drummond-Lewis J, Scher C: Propofol: A new treatment strategy for refractory migraine headache. Pain Med 2002; 3:366–9
3. Thurlow JA: Hemiplegia following general anesthesia: An unusual presentation of migraine. Eur J Anaesthesiol 1998; 15:610–2
4. Folkerts H: Migraine after electroconvulsive therapy. Convuls Ther 1995; 11:212–5
© 2007 American Society of Anesthesiologists, Inc.