Improvement of refractory migraine headache by propofol: case series
© Soleimanpour et al.; licensee Springer. 2012
Received: 10 December 2011
Accepted: 1 April 2012
Published: 15 May 2012
Several studies have been conducted on managing migraine headaches and developing effective medications for decreasing migraine-associated pain.
Intravenous propofol was prescribed (10 mg every 5 min) for eight patients with intractable migraine headaches visiting the Emergency Department. The average pain score experienced by patients was recorded using the Visual Analogue Scale at the beginning of the treatment procedure and following the injection for 30 min (5-min intervals). The patients’ reported pain scores decreased significantly (P = 0.01) from 8.87 ± 0.83 (CI: 8.17, 9.57) to 1.12 ± 0.83 (CI: 0.43, 1.82) before and 30 min following the injection.
It seems that in the treatment of intractable migraine headaches, GABAergic receptors, compared to the normal conditions, have a lower activity status.
Because of the high tendency of propofol to GABAergic receptors, it probably changes this physiological condition by activating the receptors, which results in a significant pain reduction.
KeywordsPropofol Migraine headache Visual analogue scale Emergency department GABAergic receptors
The International Association of Headache introduced acetaminophen and NSAIDs as common treatments for mild to moderate migraines, and selective 5-HT agonists (triptans) in more severe cases . However, one of the major problems in the treatment of migraines is refractory migraine headache or migraine pain lasting more than 72 h . Among the various studies that have been conducted worldwide on the treatment of refractory migraine headaches, few have been carried out on the role of propofol in the treatment of such migraine headaches. Propofol (2, 6 di-isopropyl phenol) has been used as a rapid- and short-acting intravenous medication for the induction of anesthesia and procedural sedation for many years. Its pharmacologic mechanism is related to the agonist effect on gamma-aminobutyric acid (GABA) receptors . This study evaluates the role and efficiency of intravenous propofol in several patients presenting to the emergency department.
Demographic characteristics of patients
VAS at presenting
VAS at discharge
Administered dose of propofol (mg)
Required time until palliation of headache (min)
Nausea, vomiting, photophobia
Nausea, vomiting, photo/phonophobia
Nausea, vomiting, photo/phonophobia
Nausea, vomiting, photo/phonophobia
In the mentioned cases (1 and 8) there was no need for re-admission to the ED and receiving IV medications since the severity of the pain was less than at the first presentation to the ED (VAS = 10/10 and 9/10).
So far, little work has been done regarding the role of propofol in the treatment of migraine headaches. Common medications used for the treatment of this kind of headache include opioids, NSAIDs, ergotamine compounds, triptans, antiemetics and other analgesics. During acute migraine attacks because of absorption disorders (even in the absence of nausea and vomiting), the intravenous route is preferred .
Prescription of intravenous propofol in subanesthetic doses in these eight patients caused pain relief for refractory migraine headaches. Propofol is a medication that is often used for inducing anesthesia in the operating room [3–6]. The effect of propofol on GABA receptors has been well proved by evidence from different studies . Propofol inhibits afferent sympathetic action and cardiac baroreceptor reflexes [7, 8]. Another study demonstrated that the effect of this medication on EEG during sedation with low doses is limited to the frontal lobe of the brain .
It seems that the therapeutic effects of propofol are due to its effects on the chloride channels in the β1-subunit of GABA receptors .
Drummond et al. also reported the successful treatment of two cases of resistant migraine headache with intravenous propofol .
Krusz et al. reported the first study of propofol use for headaches in 2000. This study indicated that 82 percent of patients were completely pain free. In the rest of them the pain decreased between 50 to 90 percent. None of the subjects experienced any drowsiness or disorientation after propofol prescription. Only a few patients had transient lethargy and unintelligible language (4–3 min), and one other (case 8) had spontaneous finger movements. The researchers concluded that propofol can be used in the clinic or emergency department as a definitive therapy for treatment-resistant migraines without side effects. In this study, the dramatic effect of propofol on pain relief in refractory migraine headaches was mentioned to be due to the high affinity of propofol to GABA receptors, which have a low activity status in migraines. Propofol, by stimulating these receptors, overcomes this physiological process and, as a result, migraine headaches can be cured. Researchers also considered using other medications with the same mechanism (GABA stimulators) as potential medications in treating migraine headaches and other types of headaches; this requires more research and investigation .
Furthermore, there are several other reports demonstrating the efficacy and good therapeutic effects of intravenous propofol in the treatment of refractory migraines .
As compared with other similar studies, because of its quite large sample size the present study is of significant importance for the assessment of intravenous propofol’s efficacy in the treatment of intractable migraine headaches (case series).
Also, there are studies that investigated the role of propofol in the treatment of non-migraine-type chronic headaches. For example, in a study that was conducted on patients with daily chronic headaches resistant to common treatments, more than 90% of patients showed significant improvements in their headaches, and also no symptoms have been reported. Based on the results of this study, propofol administration under reliable monitoring and in controlled conditions was suggested for daily chronic headaches .
High efficiency of intravenous propofol in the treatment of acute resistant migraine headaches can pave the way for new treatments in the field of migraine headaches and also be an appropriate replacement for other common medications for the treatment of migraines. With more complementary research, it will be possible to introduce this medication as a new and quite effective medication in the treatment of acute migraine headaches because of its wonderful effect of decreasing pain, rapid onset of action, safety and few side effects. However, there are still many questions about the pathophysiology and exact mechanism of migraines, and more studies are required to explore this field.
It seems that in refractory migraine headaches, GABAergic receptors are in a lower activity status . Because of the high tendency of propofol to these receptors, it probably changes this physiological condition by activating the receptors, which results in a significant pain reduction. Therefore, propofol can be introduced as a medication that is effective, rapid-acting, safe and with few side effects for relieving acute migraine headaches.
Every aspect of the present study was explained to the patients, and we obtained their written consent for participation in the study.
HS is Associate professor of Anesthesiology and Critical Care, Fellowship in Trauma Critical Care and CPR at the Department of Emergency Medicine, Tabriz University of Medical Sciences, Tabriz, Iran. He is also editorial board member of Emergency medicine journal (EGM) and Pakistan Journal of Biological Sciences (PJBS). AAT is Assistant professor of Neurology at the Department of Neurology, Tabriz University of Medical Sciences, Tabriz, Iran. AT and RG are Assistant professor of Internal medicine and Emergency Medicine at the Department of Emergency Medicine, Tabriz University of Medical Sciences, Tabriz, Iran, respectively. KM is an Anesthesiologist in the Nikookari Hospital, Tabriz University of Medical Sciences, Tabriz, Iran. MS is member of Gastroenterology Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran.
Visual Analogue Pain Scale
Nonsteroidal anti-inflammatory drugs.
The authors are grateful to all the health personnel and patients who participated in the study, in addition to the data collectors, supervisors and administrative staff of Emergency department of Imam Reza Hospital. Special thanks to Research Vice Chancellor Tabriz University of Medical Sciences for all the material and financial support in our study.
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