Migraines are a prevalent condition with few treatments that are both consistently effective and also safe to use on a regular basis. It is estimated that as many as 1 out of every 4 or 5 women experience migraines in the U.S. and as many as 1 out of 10 men. Many patients (up to 1.2 million each year) visit an emergency room seeking treatment for a migraine. Current treatments often have unwanted side effects that reduce the ability to take them safely for every migraine. Lidocaine intranasal has emerged as one possible abortive treatment that can be used consistently.
Treatments for Migraines
Medications available for treating migraines include:
NSAIDs: NSAIDs are often sold over-the-counter for treating pain. With long term use comes the risk of gastrointestinal bleeding and medication overuse headaches.
Antiemetics: Antiemetics may be prescribed if migraines are associated with nausea and vomiting. One possible side effect is tardive dyskinesia. Examples of antiemetics include chlorpromazine, metoclopramide, and prochlorperazine.
Antidepressants: While not effective for acute relief of a migraine, antidepressants are often prescribed to manage prevent the incidence of migraines when taken regularly. Amitriptyline may be tried first and if there are any side effects a different antidepressant may be tried. Side effects of antidepressants may include dry mouth, constipation, weight gain, sleepiness, and low blood pressure.
Triptan: Triptans like Imitrex and Maxalt work by blocking pain pathways in the brain. These medications can be very effective for managing migraines. A rare side effect is serotonin syndrome which is more likely to occur in combination with other medications.
Ergotamine: While not as commonly used anymore, ergotamine was formerly a part of a common migraine combination pill. It potentially could result in vascular occlusion and rebound headaches.
Lidocaine: Intranasal lidocaine is being researched as a treatment for acute treatment of migraines and has shown promising results to date with few side effects.
Intranasal Lidocaine Studies for Migraines and Headaches
In a controlled trial of 131 patients with diagnosed migraines, intranasal lidocaine 4% was compared to placebo. Headache was relieved within 15 minutes in 34 of 95 subjects treated with lidocaine compared with 8 of 108 subjects receiving placebo. After a 6 month follow-up, the effect of the treatment did not diminish for those patients who experienced headache relief initially.
The response in this trial may have been affected by the administration method – which was intranasal drops instead of a nasal spray. The method involved lying on bed with the head suspended off the edge of the bed and tilted toward the side of the headache. The medication is slowly dripped in the nasal passage on the side of the headache over 30 seconds and then the patient maintains the position for another 30 seconds. If the headache is bilateral the procedure is repeated for the other nasal passage. While patients did experience migraine relief, the procedure may lead to a lack of compliance or be difficult for patients to do properly. Not every patient will be capable of maintaining the correct position as required especially if they are having a migraine. A nasal spray may be easier to administer than the nasal drops as it allows the patient to be sitting or standing. The way the nasal spray propels the medications into the nasal passages may improve its reach as well.
In an earlier non-controlled clinical trial, 23 patients were treated with lidocaine 4% for their migraines. Migraine attacks were aborted in 12 of 23 patients, of which 8 were completely relieved within 5 minutes. For migraine attacks that were aborted, there were no cases of the migraine returning to more than a dull level within 24 hours. The researchers noted in this study that the treatment was more effective for unilateral attacks compared to bilateral attacks. The side effects reported included mild eye burning and stinging which subsided very quickly.
A case study involved two patients who had post-traumatic headache from traumatic head injuries. One had been hit in the head with a baseball bat and the other had fall from a chair. They experience consistent headaches that did not respond to typical medications like anti-inflammatories. After administration of intranasal lidocaine, the first patient noted a 100% reduction in pain and the second patient noted an 80% reduction. Pain relief lasted two weeks for the first patient and one week for the second patient.
How does intranasal lidocaine work for migraine? Because of its rapid onset of action, it is likely interrupting or blocking nerves. The sphenopalatine ganglion (SPG) is beneath the nasal mucosa at a depth of 1-9mm and is the likely target of intranasal lidocaine for migraine. This is the largest of 4 parasympathetic ganglia associated with facial pain and is the only one accessible via the nasal mucosa. The SPG interacts with other nerves that have an effect on cranial blood flow associated with migraines.
Compounded Lidocaine Nasal Spray 4%
A lidocaine nasal spray is not commercially available in a manufactured form however it can be made by a compounding pharmacy. Our compounding pharmacy makes lidocaine 4% nasal spray, typically in a 45mL nasal spray bottle, with a prescription.
Articles
The Use of Intranasal Sphenopalatine Ganglion Blockade for the Treatment of Post-Traumatic Headache: A Case Series – Archives of Physical Medicine and Rehabilitation
Intranasal lidocaine to prevent headache following migraine aura – Headache: The Journal of Head and Face Pain
Rapid and sustained relief of migraine attacks with intranasal lidocaine: preliminary findings – Headache: The Journal of Head and Face Pain
Evaluation of efficacy of intra-nasal lidocaine for headache relief in patients refer to emergency department – Journal of Research in Medical Sciences