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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 100-104

Symptom-free status after prolonged suffering with refractory chronic migraine: A case report


1 VCPC Research Foundation, Department of Clinical Research, Rudrapur, Uttarakhand, India
2 Department of Medicine and Surgery, SK Ramachandani Orthopedic Hospital, Kota, Rajasthan, India
3 Padaav – Speciality Ayurvedic Treatment Centre, Dehradun, Uttarakhand, India

Date of Submission12-Feb-2021
Date of Acceptance25-Sep-2021
Date of Web Publication14-Dec-2021

Correspondence Address:
Dr. Vaidya Balendu Prakash
VCPC Research Foundation, Prakash Villa, NH-74, Danpur Area, Rudrapur - 263 153, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacr.jacr_14_21

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  Abstract 


Migraine is ranked sixth among disability-causing diseases in the world. Patients with chronic migraine suffer from headaches 15 days or more in a month. Refractory migraine patients fail to respond to conventional treatments even after avoiding all migraine triggers. These patients continue to suffer in the absence of any established cause and cure. A patient suffering from chronic refractory migraine for about 37 years presented with daily headache associated with symptoms of nausea, vomiting, phonophobia, and photophobia. The patient underwent 9 months Ayurvedic treatment, including initial three weeks of residential treatment. The patient reported a considerable reduction in Visual Analog Scale score, Migraine-Induced Disability Assessment Score, duration/frequency of headache, consumption of analgesics, and improved general well-being indicating the therapeutic efficacy of Ayurvedic treatment.

Keywords: Chronic Migraine, Refractory Migraine, Abhraka bhasma, Sitopaladi churna


How to cite this article:
Prakash VB, Ramachandani G D, Prakash VS, Sharma S, Tiwari S. Symptom-free status after prolonged suffering with refractory chronic migraine: A case report. J Ayurveda Case Rep 2021;4:100-4

How to cite this URL:
Prakash VB, Ramachandani G D, Prakash VS, Sharma S, Tiwari S. Symptom-free status after prolonged suffering with refractory chronic migraine: A case report. J Ayurveda Case Rep [serial online] 2021 [cited 2022 Aug 8];4:100-4. Available from: http://www.ayucare.org/text.asp?2021/4/3/100/332432




  Introduction Top


Migraine is the most common form of headache, which is characterized by episodic headaches. In the absence of any pathological or radiological tests, the diagnosis of migraine is based on an examination following the laid diagnostic criteria of the International Headache Society.[1] The disease may turn from episodic to Chronic Migraine (CM), Refractory Migraine (RM), and Medication Overuse Headache (MOH). The chronic and refractory state of migraine causes substantial disability to the sufferers because of the unpredictable and limited effects of conventional treatment. Analgesics and Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) remain the first drug of choice for acute management of mild-to-moderate migraine. Ergot derivatives and/or triptans may also be used as migraine specific medications.[2] In case of chronic migraine, prophylaxis along with acute management of migraine becomes a necessity. Prophylactic treatment of CM includes oral administration of beta-blockers, anti-convulsants, calcium-channel blockers, tricyclic anti-depressants, serotonin antagonists, anti-hypertensives, and anti-depressants.[3] Other preventive therapies include, Onabotulinumtoxin A (OBT-A) injections and topiramate. Treatments targeting Calcitonin Gene-Related Peptide are also emerging as prophylaxis for CM.[3] However, these treatments have certain adverse effects with the development of MOH being the most troublesome one, as it only worsens the pain condition.

Patients with chronic migraine experience migraine symptoms for 15 days or more in a month over a period of minimum three months.[4] Refractory headaches are those that impact the quality of life despite modification of triggers, lifestyle factors and adequate trails of acute and preventive medicines with established efficacy. A patient is considered to have refractory migraine when he/she fails to respond to 3–4 adequate trials of preventive medicines, alone or in combination, from at least 2 of 4 drug classes including beta-blockers, anticonvulsants, tricyclics, and calcium channel blockers, and also fails to respond to adequate trials of abortive medicines, including both a triptan and dihydroergotamine intranasal or injectable formulations and either NSAIDs or combination of analgesics, unless contraindicated.[5] MOH is headache occurring on 15 or more days per month developing as a consequence of regular overuse of acute or symptomatic headache medication (on 10 or more, or 15 or more days per month, depending on the medication) for more than three months. MOH is described as headache present on more than 15 days per month that has markedly worsened during the period of medication overuse in patients with regular overuse of one or more medicines for headache for more than three months. Studies suggest that the mean time of onset of MOH is 1.7 years for triptan users, 2.7 years for patients taking ergots, and 4.8 years for those using analgesics if taken regularly.[6]

The prevalence of migraine is on a rise globally. Around 12% of the world, population is affected by migraine.[7] About 5%–8% of all migraineurs convert into CM patients and about 5% develop RM, with the overall prevalence of RM/CM at around 2%–3%.[8] MOH occurs in 0.5%–2.6% population, while about 11%–70% Chronic migraine patients have been reported to develop MOH.[8] The substantial burden caused by the disease in association with the limitations of available therapies lead patients toward complementary and alternative treatment. Here, we present a case of a 61-year-old orthopedic surgeon from Rajasthan, India, who had developed refractory chronic migraine.


  Patient Information Top


A 58-year-old man presented at our center in October 2017 with 37 years of history of headache. The patient is nondiabetic, hypertensive and is a known case of hypothyroidism. Both the conditions are well under control with the help of allopathic medicines. He is vegetarian, nonalcoholic, and nontobacco user. He had daily headaches with Visual Analog Scale (VAS) score up to 9–10 and Migraine-Induced Disability Assessment Score (MIDAS) about 66, indicating severe disability. On examination, he was found to have Kapha-pitta dominant pulse and pain in right hypochondrium on deep palpation. He had bilateral pedal edema.

The patient was initially diagnosed for migraine in the year 1980 and was put on painkillers as and when required. The migraine attacks continued with increased frequency and intensity of pain. These attacks were equally distributed between right and left temporal region. The pain was throbbing in nature with severity 7-9 on VAS and was associated with vomiting at its peak.[9] Factors that aggravated his migraine attacks were missing of meals, travelling, exposure to sun, stress, exertion, specific odors, lemon and lack of sleep. He only got relief in pain after taking painkillers. The patient consulted a neurologist in Udaipur and was advised betablockers, tryptomers, calcium channel blockers, and painkillers (as and when required). In 2002, he was advised OBT-A therapy by a leading Neurologist in Mumbai. He was given Botulinum toxin A injections in forehead and neck every six months. He had no severe attacks for about six years but then resistance to the drug developed and pain restarted.

In December 2013, the patient was admitted to a multi-specialty modern hospital in Gurgaon with a complaint of severe headache. He was diagnosed for chronic migraine with severe medication overdose headache. He was put on intravenous steroids for about 16 days and later oral steroids for three months. Occipital nerve radiofrequency ablation was done. He had relief in pain and the procedure was repeated after about three months. However, he did not have much relief after the second ablation and the attacks started to recur.

The patient consulted a leading neurologist at a multi-specialty modern hospital in Mumbai in August 2014 and was declared to have intractable (refractory) migraine. Bilateral occipital nerve stimulation and octad electrode implantation along both greater occipital nerves with Internal Pulse Generator (IPG) insertion was done. The patient did not experience complete relief and also complained of mild pain and discomfort at the IPG site due to the formation of keloid. In April 2016, during follow-up visit to the hospital in Mumbai, the implant was removed. Since then, he again started having attacks of migraine and continued to manage the pain with painkillers until October 2017.


  Therapeutic Intervention Top


The patient was examined and admitted for supervised indoor treatment for initial three weeks. He was put on Ayurvedic treatment [Table 1]. Tea, coffee, aerated drinks, refined flour, packaged food items, and reheated food were completely stopped in his diet. He was advised 1800–2200 Calorie daily balanced diet, divided into three meals and three snacks with eight hour of undisturbed sleep at night [Table 2]. He was also prescribed Nasya and Shirodhara during the indoor treatment. A combination of powders of Sootashekhara rasa,[10] Abhraka bhasma,[11] Sitopaladi churna,[12] Punarnava mandora (fortified with 18 herbs), Narikela lavana,[13] Rasona vati[13] and Godanti mishrana (250 mg tablet containing Godanti bhasma, Rasadi vati, Jawaharmohra pishti, Chandra arka, and Gojihva arka).[13] At discharge, the patient was advised to continue the same treatment with all the diet and lifestyle related advices. The treatment was continued for nine months.
Table 1: Ayurvedic medicines prescribed

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Table 2: Daily diet and lifestyle prescribed

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  Timeline Top


The detailed timeline of the case is depicted in [Table 3].
Table 3: Timeline of the case

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  Follow-up and Outcome Top


The patient started to show improvement within the initial three week of treatment. His VAS score, number of headache days and drug consumption to control symptoms dropped down gradually [Graph 1]. Marked effect was seen on MIDAS score [Graph 2]. Associated symptoms, including nausea, vomiting, phonophobia, and photophobia disappeared completely after 30 days of treatment. No adverse effects of the treatment were reported. After two years of treatment, the patient still reported satisfaction improvement. He was experiencing occasional pain with minimal intensity (VAS = 1) of headache that subsides on its own.




  Discussion Top


CM, RM, and MOH are progressive stages of Migraine. The conventional treatment is aimed at bringing maximum relief in symptoms and minimizing the acute exacerbations of migraine attacks. The patients are given prophylactic and abortive medicines, which may cause moderate to severe side effects. The presented case is a classic case of migraine. Episodic headaches started in his early twenties and gradually converted into chronic migraine, refractory migraine, and medication overuse headache. In this case, migraine and its treatment had adversely affected the patient's personal, professional, and social life. The regular use of intravenous painkillers had damaged his veins so badly that he was not able to wear any footwear because of pedal edema. In a desperate attempt to get rid of the disease, the patient had also undergone OBT-A therapy and occipital nerve radiofrequency ablation surgery, but there was not much effect. Although the patient had established diagnosis of CM/RM/MOH, he was evaluated on Ayurvedic principles of diagnosis, including Darshanam (~visual), Sparshanam (~palpation), and Prashnam (~questioning) followed by Ashtavidha parikshana (~examination of eight factors including Nadi, Mutra, Mala, Jihwa, Sabdam, Sparsham, Drik, and Akrithi). He was found to have Pitta-kapha dominant pulse. There were signs of acid-alkali imbalance and delayed digestion with lots of flatulence and abdominal distension. He had pain on palpation in the right hypochondrium and tenderness in the right iliac fossa.

Ayurveda emphasizes on the balance of Vata-pitta-kapha for healthy state of body. There are laid guidelines related to daily routine, diet and lifestyle in Ayurveda depending on place, weather, and age of individual. These practices are diminished these days due to the pressure of today's world, especially in big cities. Here, the patient was put on Ayurvedic treatment after stopping all conventional medicine. He was prescribed a disciplined regime of sleep, diet, and water intake along with Ayurvedic medicines. The patient reported congestion and headache on waking up sometimes, indicating sinusitis-related migraine. Hence, he was prescribed Nasya using eight drops of cold compressed mustard oil in each nostril for 21 days. Being a senior medical professional himself, he was quite stressed with his chronic migraine. Hence, Takra shirodhara was advised for 8 days as he was sensitive to the smell of oils. There was gradual effect on both the intensity and frequency of pain with overall improvement in general well-being.

Migraine was ascribed by Tissot as a result of reflexes of the gall bladder, stomach, and uterus.[14] Later on, it was considered as supraorbital neurological disorder. The Ayurvedic diagnosis and treatment is very similar to the approach of Tissot. The treatment is based on a hypothesis that the symptoms of migraine are similar to that of Shleshma pitta. The said hypothesis is further strengthened by the fact that the prescribed Ayurvedic formulations, Sootashekara rasa, Abhraka bhasma and Sitopaladi churna, prescribed are Pitta shamak and help in balancing of pH within the gut. Narikela lavana is used to reduce Pittashaya shotha (~inflammation of the gall bladder) and helps in the flow of bile in the gut. Rasona vati is well known for Vatanulomana (~enhancing the movement of gases downward) in the body. Godanti mishrana is used for treating malaise, headache and is Pitta shamaka. Thus, all medicines were given to lower Pitta, reduce inflammation of the gall bladder and gut and improve the peristalsis of the intestine and colon. None of the formulations have any ingredient with properties to relieve pain. A pharmacological study on these formulations has also indicated toward the said hypothesis as these formulations have no analgesic, anti-inflammatory, anti-depressant or anti-epileptic effect and have no effect on neurobehavioral parameters (data on file). This further strengthens the stated hypothesis as these medicines could play a role in alleviating Shleshma pitta and abdominal symptoms only and had no effect on pain. Significant improvement in this chronic case reveals the usefulness of Ayurveda procedures, the management strategies in such complex conditions. Ayurvedic treatment was well tolerated by the patient without any adverse events. The observation of the study indicates that Ayurveda has a significant and sustainable effect in the prevention of migraine.


  Conclusion Top


The case report indicates the therapeutic efficacy of Ayurvedic treatment in bringing notable long-term relief in Chronic and Refractory Migraine.

Declaration of patient consent

Authors certify that they have obtained patient consent form, where the patient/caregiver has given his/her consent for reporting the case along with the images and other clinical information in the journal. The patient/caregiver understands that his/her name and initials will not be published and due efforts will be made to conceal his/her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Schulman EA, Lake AE 3rd, Goadsby PJ, Peterlin BL, Siegel SE, Markley HG, et al. Defining refractory migraine and refractory chronic migraine: Proposed criteria from the refractory headache special interest section of the American Headache Society. Headache 2008;48:778-82.  Back to cited text no. 5
    
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Kristoffersen ES, Lundqvist C. Medication-overuse headache: Epidemiology, diagnosis and treatment. Ther Adv Drug Saf 2014;5:87-99.  Back to cited text no. 6
    
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Yeh WZ, Blizzard L, Taylor BV. What is the actual prevalence of migraine? Brain Behav 2018;8:e00950.  Back to cited text no. 7
    
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Fisher MA, Jan A. Medication-overuse Headache (MOH). StatPearls; 2020. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538150/. [Last accessed on 2021 Sep 15].  Back to cited text no. 8
    
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Delgado DA, Lambert BS, Boutris N, McCulloch PC, Robbins AB, Moreno MR, et al. Validation of Digital Visual Analog Scale Pain Scoring With a Traditional Paper-based Visual Analog Scale in Adults. J Am Acad Orthop Surg Glob Res Rev. 2018;2:e088. doi: 10.5435/JAAOSGlobal-D-17-00088.  Back to cited text no. 9
    
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Acharya YT. Siddha Yoga Sangrah. Jhansi, India: Baidyanath Bhawan; 1935. p. 51.  Back to cited text no. 10
    
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Anonymous. Rasatantrasarava Siddhaprayoga Sangraha. Part 1, Kharaliya rasayana no. 80. Ajmer: Krishna Gopal Ayurveda Bhavan; 1980. p. 161.  Back to cited text no. 11
    
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Anonymous. Rasatantrasarava Siddhaprayoga Sangraha. Part 1, Kharaliya rasayana no. 80. Ajmer: Krishna Gopal Ayurveda Bhavan; 1980. p. 444-5.  Back to cited text no. 12
    
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Vaidya PB, Vaidya BS, Vaidya SK. Response to Ayurvedic therapy in the treatment of migraine without aura. Int J Ayurveda Res 2010;1:30-6.  Back to cited text no. 13
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Eadie MJ. An 18th century understanding of migraine – Samuel Tissot (1728-1797). J Clin Neurosci 2003;10:414-9.  Back to cited text no. 14
    



 
 
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Introduction
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