Abstract
INTRODUCTION: Migraines are the 3rd most common disease in the world. The trigeminovascular system's role in migraine's pathophysiology provides a rational for using Intraarterial (IA) blockade of the trigeminal ganglion for migraine treatment. Recent studies, has highlighted middle meningeal artery (MMA) as an effective pathway for IA therapy in the treatment of refractory headaches. We report the result of IA injection of medications into the MMA in a patient with refractory migraines. METHOD: We present a case of 74 year‐old male with chronic migraine who presented with 3 days of status migrainosus resistant to abortive medications. Pain was described as constant 9 out 10 intensity throbbing headache with migrenous features. Previously, patient tried different prophylactic treatments including CGRP antagonists (Erenumab and Fremanezumab), Antiepileptics (Topiramate and Valproic acid), Tricyclic antidepressants (Nortriptyline), and botulinum toxin with no improvement of headaches. He was offered a trial of bilateral MMA IA infusion of lidocaine, propofol and methylprednisolone after which he had significant improvement and became headache free for 2 weeks. After 2 weeks, daily headaches recurred but with 3 out of 10 intensity. RESULTS: Procedure was performed with trans‐radial approach. 021 Prowler select plus microcatheter was advanced over 014 microwire into the frontal branch of the left MMA. Medications were infused into the microcatheter as follows: 10 mg of lidocaine, 10 mg of methylprednisolone and 5 mg of propofol each slowly infused over 5 minutes. Then, the microcatheter was advanced to the petrosquomosal branch of left MMA and same medications were infused. A similar procedure was performed in the right MMA. DISCUSSION: During migraine attack, activation of trigeminal nerve results in release of inflammatory neuropeptides (e.g., CGRP, Substance P) from the trigeminal nerve ending which contributes to migraine headache. Suppression of trigeminal nerve activity has been reported with IA injection of lidocaine into MMA in refractory trigeminal neuralgia patients. This suggests IA lidocaine therapy administered via MMA might also be effective in treating migraines. We observed similar effects from IA injection of lidocaine, methylprednisolone, and propofol into the MMA in a patient with refractory migraines. In a similar way, patients with other primary headaches disorders related to trigeminal nerve such as Trigeminal Autonomic Cephalalgia may benefit from similar treatments. Due to limited studies, we are unable to identify procedure risks such as dissection or inadvertent involvement of other arteries. More research is needed to determine the safety and efficacy of this procedure. [Image: see text]