Available via license: CC BY 4.0
Content may be subject to copyright.
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
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: Keywords:
Keywords: Intravenous lidocaine; Cluster headache
RESUMORESUMO
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.
PP
PP
Palavrasalavras
alavrasalavras
alavras--
--
-chave: chave:
chave: chave:
chave: Lidocaína endovenosa; Cefaleia em salvas
CASE REPORTCASE REPORT
CASE REPORTCASE REPORT
CASE REPORT
Paulo Sérgio Faro Santos1, Renato Endler Iachinski2, Henry Koiti Sato2, Maria Tereza Moraes Souza
Nascimento2, Ricardo Krause Martinez de Souza2, Vanessa Rizelio2, Pedro André Kowacs2
1Medical Student, Universidade Federal de Sergipe – UFS, Aracaju, SE, Brazil
2Neurology 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
1. Fischera M, Marziniak M, Gralow I, Evers S. The incidence and
prevalence of cluster headache: a meta-analysis of population-
based studies. Cephalalgia. 2008;28(6):614-8.
2. Goadsby PJ, Cittadini E, Burns B, Cohen AS. Trigeminal
autonomic cephalalgias: diagnostic and therapeutic
developments. Curr Opin Neurol. 2008;21(3):323-30.
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
JC. Response to intravenous lidocaine in a patient with SUNCT
syndrome. Cephalalgia. 2010;30(1):110-2.
5. Matharu MS, Cohen AS, Goadsby PJ. SUNCT syndrome responsive
to intravenous lidocaine. Cephalalgia. 2004;24(11): 985-92.
6. Maciewicz R, Chung RY, Strassman A, Hochberg F, Moskowitz M.
Relief of vascular headache with intravenous lidocaine: clinical
observations and a proposed mechanism. Clin J Pain. 1988;
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
PP
PP
Pedro André Kedro André K
edro André Kedro André K
edro André Kowacsowacs
owacsowacs
owacs
Instituto de Neurologia de Curitiba
Rua Jeremias Maciel Perretto 300 – Bairro Ecoville
81210-310 – Curitiba, PR, Brazil
e-mail: pkowacs@gmail.com
7. Marmura M, Rosen N, Abbas M, Silberstein S. Intravenous
lidocaine in the treatment of refractory headache: a
retrospective case series. Headache. 2009;49(2):286-91.
Erratum in Headache. 2009 May;49(5):803.
8. Heavner JE. Local anesthetics. Curr Opin Anaesthesiol.
2007;20(4):336-42.
9. Lauretti GR. Mechanisms of analgesia of intravenous lidocaine.
Rev Bras Anestesiol. 2008;58(3):280-6. Article in English,
Portuguese]
10. Kittrelle JP, Grouse DS, Seybold ME. Cluster headache: local
anesthetic abortive agents. Arch Neurol. 1985;42(5):496-8.
11. Rapoport AM, Bigal ME, Tepper SJ, Sheftell FD. Intranasal
medications for the treatment of migraine and cluster headache.
CNS Drugs. 2004;18(10):671-85.
12. Costa A, Pucci E, Antonaci F, Sances G, Granella F, Broich G,
Nappi G. The effect of intranasal cocaine and lidocaine on
nitroglycerin-induced attacks in cluster headache. Cephalalgia.
2000;20(2):85-91.
13. Robbins L. Intranasal lidocaine for cluster headache. Headache.
1995;35(2):83-4.
14. Leone M, Bussone G. Pathophysiology of trigeminal autonomic
cephalalgias. Lancet Neurol. 2009;8(8):755-64.
Received: 12/20/2011
Accepted: 1/22/2012
