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January 2014
authorizing use of Botox. Patients are exposed to potential systemic side effects to drugs that are not FDA approved for CM. Delaying the use of Botox with unproven, non-FDA-approved therapies only increases the risk of refractory chronification of CM.5 4. Botox should be utilized for the treatment of CM without first requiring treatment with non-FDAapproved drug treatments. James A. Charles, MD Department of Neurosciences, New Jersey Medical School, Bayonne, NJ, USA
REFERENCES 1. https://www.unitedhealthcareonline.com/ccmcontent/ ProviderII/UHC/en-US/Assets/ProviderStatic Files/ProviderStaticFilesPdf/Tools%2520and%2520 Resources/Policies%2520and%2520Protocols/Medical %2520Policies/Drug%2520Policies/Botulinum_toxin _policy.pdf. 2. http://www.cigna.com/health/provider/medical/forms/ Botox-041310.pdf. 3. https://services3.horizon-bcbsnj.com/hcm/MedPol2.nsf. 4. https://www.oxhp.com/secure/policy/botox _commercial_711.html. 5. Scher AI, Lipton RB, Stewart W. Risk factors for chronic daily headache. Curr Pain Headache Rep. 2002;6:486-491.
Vagus Nerve Stimulation for Refractory Cluster Headaches Tepper and Stillman provide an excellent overview of treatment options in refractory cluster headache patients.1 While they mention noninvasive vagus nerve stimulation (VNS), they fail to discuss a possibly more effective option, from which the idea for noninvasive VNS was derived. This option is VNS using an implanted electrode that provided very good relief in both patients with refractory cluster headaches in whom it was tried.2 VNS is approved by the Food and Drug Administration for refractory epilepsy and depression, and considering that anticonvulsants and antidepressants are effective in the treatment of headaches, it is likely that VNS will work for headache patients as well. Alexander Mauskop, MD, FAAN Neurology, New York Headache Center, New York, NY, USA
REFERENCES 1. Tepper SJ, Stillman MJ. Cluster headache: Potential options for medically refractory patients (when all else fails). Headache. 2013;53:1183-1190. 2. Mauskop A. Vagus nerve stimulation relieves chronic refractory migraine and cluster headaches. Cephalalgia. 2005;25:82-86.
Classification Challenge in Migrainous Infarction The International Classification of Headache Disorders, 3rd Edition (ICHD-3) beta version defines migrainous infarction as 1 or more otherwise typical aura symptoms that persist beyond 1 hour with neuroimaging confirmation of an ischemic infarction in the affected territory.1 Here we describe a woman with migraine with brainstem aura, who experienced acute-onset left sensorimotor deficits in addition to her typical aura symptoms in the midst of a prolonged, but otherwise typical attack. Magnetic resonance imaging (MRI) of the brain revealed a pontine lesion consistent with an ischemic stroke. Our case illustrates potential limitations of the ICHD-3 beta definition of migrainous infarction. Our patient developed episodic headaches that fulfilled ICHD-3 beta criteria for episodic migraine without aura in her adolescence.1 At the age of 30, she began to experience episodes of transient neurological symptoms antecedent to her typical headache attacks. The symptoms included vertigo, tinnitus, hypacusis, gait unsteadiness, disorientation, and severe nausea and vomiting slowly evolving over hours, lasting 1-5 days prior to the onset of headache and usually continuing throughout the duration of a headache attack. On occasion, she would experience the symptom complex without associated headache. Postictal neurologic examination and brain MRI at that time were unremarkable. At the age of 42, she developed the typical constellation of aura symptoms followed by a 2-week period of status migrainosus. Several days into the headache phase, she experienced acute, maximal-at-onset dysarthria and left face, Conflicts of Interest: Dr.Vollbracht has received honoraria from the American Headache Society. Dr. Robbins has received honoraria from Medlink Neurology and book royalties from Headache (Neurology in Practice Series). Dr. Kister reports no disclosures. Study Funding: None.
January 2014
authorizing use of Botox. Patients are exposed to potential systemic side effects to drugs that are not FDA approved for CM. Delaying the use of Botox with unproven, non-FDA-approved therapies only increases the risk of refractory chronification of CM.5 4. Botox should be utilized for the treatment of CM without first requiring treatment with non-FDAapproved drug treatments. James A. Charles, MD Department of Neurosciences, New Jersey Medical School, Bayonne, NJ, USA
REFERENCES 1. https://www.unitedhealthcareonline.com/ccmcontent/ ProviderII/UHC/en-US/Assets/ProviderStatic Files/ProviderStaticFilesPdf/Tools%2520and%2520 Resources/Policies%2520and%2520Protocols/Medical %2520Policies/Drug%2520Policies/Botulinum_toxin _policy.pdf. 2. http://www.cigna.com/health/provider/medical/forms/ Botox-041310.pdf. 3. https://services3.horizon-bcbsnj.com/hcm/MedPol2.nsf. 4. https://www.oxhp.com/secure/policy/botox _commercial_711.html. 5. Scher AI, Lipton RB, Stewart W. Risk factors for chronic daily headache. Curr Pain Headache Rep. 2002;6:486-491.
Vagus Nerve Stimulation for Refractory Cluster Headaches Tepper and Stillman provide an excellent overview of treatment options in refractory cluster headache patients.1 While they mention noninvasive vagus nerve stimulation (VNS), they fail to discuss a possibly more effective option, from which the idea for noninvasive VNS was derived. This option is VNS using an implanted electrode that provided very good relief in both patients with refractory cluster headaches in whom it was tried.2 VNS is approved by the Food and Drug Administration for refractory epilepsy and depression, and considering that anticonvulsants and antidepressants are effective in the treatment of headaches, it is likely that VNS will work for headache patients as well. Alexander Mauskop, MD, FAAN Neurology, New York Headache Center, New York, NY, USA
REFERENCES 1. Tepper SJ, Stillman MJ. Cluster headache: Potential options for medically refractory patients (when all else fails). Headache. 2013;53:1183-1190. 2. Mauskop A. Vagus nerve stimulation relieves chronic refractory migraine and cluster headaches. Cephalalgia. 2005;25:82-86.
Classification Challenge in Migrainous Infarction The International Classification of Headache Disorders, 3rd Edition (ICHD-3) beta version defines migrainous infarction as 1 or more otherwise typical aura symptoms that persist beyond 1 hour with neuroimaging confirmation of an ischemic infarction in the affected territory.1 Here we describe a woman with migraine with brainstem aura, who experienced acute-onset left sensorimotor deficits in addition to her typical aura symptoms in the midst of a prolonged, but otherwise typical attack. Magnetic resonance imaging (MRI) of the brain revealed a pontine lesion consistent with an ischemic stroke. Our case illustrates potential limitations of the ICHD-3 beta definition of migrainous infarction. Our patient developed episodic headaches that fulfilled ICHD-3 beta criteria for episodic migraine without aura in her adolescence.1 At the age of 30, she began to experience episodes of transient neurological symptoms antecedent to her typical headache attacks. The symptoms included vertigo, tinnitus, hypacusis, gait unsteadiness, disorientation, and severe nausea and vomiting slowly evolving over hours, lasting 1-5 days prior to the onset of headache and usually continuing throughout the duration of a headache attack. On occasion, she would experience the symptom complex without associated headache. Postictal neurologic examination and brain MRI at that time were unremarkable. At the age of 42, she developed the typical constellation of aura symptoms followed by a 2-week period of status migrainosus. Several days into the headache phase, she experienced acute, maximal-at-onset dysarthria and left face, Conflicts of Interest: Dr.Vollbracht has received honoraria from the American Headache Society. Dr. Robbins has received honoraria from Medlink Neurology and book royalties from Headache (Neurology in Practice Series). Dr. Kister reports no disclosures. Study Funding: None.
