|Year : 2019 | Volume
| Issue : 4 | Page : 238-240
Revisiting the expanded use of hyperbaric oxygen therapy for treatment of resistant migraines
David V Matera1, Brian Smith2, Benjamin Lam3
1 Department of General Surgery, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA, USA
2 Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
3 Division of Plastic and Reconstructive Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
|Date of Submission||15-Jul-2019|
|Date of Decision||18-Jul-2019|
|Date of Acceptance||23-Sep-2019|
|Date of Web Publication||30-Dec-2019|
David V Matera
Department of General Surgery, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA
Source of Support: None, Conflict of Interest: None
There are currently 13 indications approved by the U.S. Food and Drug Administration for use of hyperbaric oxygen therapy. The European Consensus Conference on Hyperbaric Medicine has 28 indications approved for its use. However, neither includes the use of hyperbaric oxygen therapy for neurological conditions such as migraines with aura. Recent research has made the attempt to fully understand the use of hyperbaric therapy in treatment of neurological conditions, but results have so far been inconclusive. We report a 23-year-old female with an 11-year history of migraines with aura who has received inadequate pharmacological treatment for her migraines since she began having them. Migraines have led her to significant loss of function. The patient underwent treatment at 1.5 absolute atmospheres in a hyperbaric chamber Monday through Friday for 1 hour each day for a total of 40 sessions but reported missing a few sessions over the 8-week period. No more than 1 session during a given week was missed and the patient received no other treatments for her migraines throughout this time period. By her 24th treatment, the patient had only experienced a single migraine with aura but without debilitating pain. The patient stated she had never had a migraine with such little intensity prior to initiation of hyperbaric treatment and did not have to take any days off from work or school. Follow-up at the end of her 40-day treatment period revealed a highly-satisfied patient who had only experienced the single episode of a mild migraine during the entire course of treatment. Thus, we believe that further research needs to be done to realize the full potential of hyperbaric oxygen therapy in the treatment of neurological conditions as this case highlights the potential for using hyperbaric oxygen therapy as prophylaxis against attacks in patients with treatment resistant migraines with aura.
Keywords: hyperbaric chambers; hyperbaric oxygen therapy; vascular headaches; migraines; aura; vasoconstriction; migraine with aura; indications for hyperbaric oxygen
|How to cite this article:|
Matera DV, Smith B, Lam B. Revisiting the expanded use of hyperbaric oxygen therapy for treatment of resistant migraines. Med Gas Res 2019;9:238-40
|How to cite this URL:|
Matera DV, Smith B, Lam B. Revisiting the expanded use of hyperbaric oxygen therapy for treatment of resistant migraines. Med Gas Res [serial online] 2019 [cited 2020 Feb 19];9:238-40. Available from: http://www.medgasres.com/text.asp?2019/9/4/238/273963
| Introduction|| |
The use of hyperbaric oxygen therapy (HBO) has been a widely-accepted form of treatment for certain conditions. Hyperbaric oxygen therapy involves the inhalation of 100% oxygen in a hyperbaric chamber at a pressure higher than 1 atm or 760 mmHg. The beneficial effects of HBO results from generating physiologic hyperoxia in tissue by fully saturating hemoglobin molecules and increasing the amount of oxygen dissolved in the plasma. This allows tissue to meet its oxygen demand through the dissolved oxygen alone without the need to utilize the oxygen linked to hemoglobin.,,,, As a class II medical device, hyperbaric chambers are currently approved for 13 indications by the U.S. Food and Drug Administration (FDA) and Hyperbaric Medical Society., Indications currently include adjuvant therapy in wound ischemia, thermal burn treatment, blood loss anemia, air embolisms, carbon monoxide poisoning, clostridial myonecrosis, crush injury, decompression sickness, chronic refractory osteomyelitis, necrotizing soft-tissue infections, radiation tissue injury, ischemic skin grafts and flaps, and intracranial abscess [Table 1], but does not include neurologic conditions.,,, The 2016 European Consensus Conference on Hyperbaric Medicine resulted in a list of 9 indications for HBO to be used as a primary therapy, with an additional 13 indications where there is acceptable evidence that HBO may be used as treatment, as well as 6 indications where HBO may be considered as an optional modality. Amongst the 13 FDA-approved indications and the 28 indications that resulted from the 2016 European Consensus Conference on Hyperbaric Medicine, neither group includes treatment for neurological conditions such as migraines with aura.,,, Current treatments for migraines and other headaches are based around relieving the symptoms through the reduction of cerebral blood flow. HBO substantially increases the amount of arterial oxygen and therefore effectively achieves cerebral vasoconstriction, thus treating the migraine., Based on this case report, we believe the current approved indications for HBO need to be expanded to include resistant migraines after further randomized control trials demonstrate efficacy in a larger patient population [Table 1].
|Table 1: Current U.S. Food and Drug Administration approved indications and recommended update to the current indications for hyperbaric oxygen therapy,|
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| Case History|| |
We present a 23-year-old female with a self-reported history of migraines with aura since the age of 12 with no other relevant medical history. She described her migraines as severe in nature lasting 4–6 hours, 3 times monthly on average. Her extreme pain and sensitivity to light and sound often impaired daily function, causing a loss of vision and inability to focus on tasks at hand. The patient also reported frequent abdominal pain leading to emesis during her migraine attacks. Overall, the migraines hindered her functional status as she had missed many days of school and work due to her condition. She had been managed by her primary care physician since the onset of her migraines at an early age; however, she experienced migraines refractory to Imitrix and adjustments to birth control. The patient would typically get mild relief using Excedrin, caffeine consumption, removal of light, and use of ice packs. Evaluation of this patient prior to initiation of treatment revealed no contraindications to HBO. The patient underwent treatment at 1.5 absolute atmospheres in a hyperbaric chamber Monday through Friday for 1 hour each day, for a total of 40 sessions, but reported missing a few sessions over the 8-week period. No more than one session during a given week was missed and the patient received no other treatments for her migraines throughout this time period. By her 24th treatment, the patient had only experienced a single migraine with aura but without debilitating pain. The patient stated she has never had a migraine with such little intensity prior to initiation of hyperbaric treatment and did not have to take any days off from work or school during treatment. Follow-up at the end of her 40-day treatment period revealed a highly-satisfied patient who had only experienced the single episode of a mild migraine during the entire course of treatment. It is important to indicate that the patient did not receive any additional therapy during HBO treatments.
| Discussion|| |
The most recent guidelines for management of acute migraine attacks involve use of triptans, non-steroidal anti-inflammatory drugs and antiemetics. Prophylactic treatment often includes the use of beta blockers, tricyclic antidepressants, and anticonvulsants. Response to such therapies is highly variable and is often effective only in a select group of patients. They are often prescribed based upon the patient’s tolerability of the medication and comorbid conditions. Migraine attacks with aura are often less responsive to triptans and carry an even more differentiated response when compared to a migraine without aura., Thus, a great need for alternative treatments for migraines exists, especially for patients whose migraines are refractory to current pharmacologic therapies.
As illustrated by this report, HBO may provide a novel approach in reducing the disability of the migraineur by providing relief, and by reducing the frequency of attacks refractory to pharmacologic therapy. While the exact inflammatory mediators responsible for migraine headaches are still unknown, it is known that inflammation plays a role in the activation of the trigeminovascular system leading to migraines with the characteristic throbbing pain.,, The peripheral activation of the trigeminovascular nociceptors in the dura mater leads the release of vasoactive dilators including calcitonin gene-related peptide causing long lasting stimulation and vasodilation.,, The beneficial effects of HBO are caused through the physiologic consequences of 100% inspired oxygen and exposure to elevated atmospheric pressures. This leads to higher levels of dissolved oxygen in plasma and subsequent arterial constriction in the brain, thus aborting and preventing the migraine.,,,,,
The current understanding of the pathophysiology behind migraines with aura combined with the increasing evidence supporting the anti-inflammatory and anti-vasodilatory effects of HBO, suggests that our patients’ relief could be related to HBO decreasing the inflammatory response that leads to the activation of the trigeminovascular pathway.,,, A study by Myers et al. demonstrated a significant reduction (P < 0.05) in migraine relief in patients undergoing HBO versus those who underwent normobaric oxygen therapy. Wilson et al. showed a significant decrease in subjective pain in those who underwent HBO versus the control group of females with migraine with aura. Other studies by Eftedal et al.,, showed insignificant prophylactic measure against migraines with the use of HBO. It is important to note that these studies have limited sample sizes. A Cochrane review on the usage of HBO to prevent migraines showed no evidence to suggest that HBO could prevent migraine attacks, reduce the incidence of nausea and vomiting, or reduce the requirement for rescue medication based upon 11 trials. On the contrary, we present a patient who had a reduction in frequency, intensity, symptomatology, and need for rescue medications after HBO treatment. To truly judge the efficacy of HBO and take to into account the inherent variability in response to different treatments, larger studies are needed. Our case of this 23-year-old female who experienced a reduction in the frequency and intensity of her migraines after HBO provides the evidence for the use of HBO in the management of chronic migraine. Of note, there has been a limited follow up time with the patient so we are unable to determine how long this treatment modality will remain effective in the long term. The purpose of this article is to expand the currently FDA-approved indications for HBO, such as migraine, headaches based on randomized controlled studies addressing long lasting efficacy in large patient populations. While there has been progress both in the understanding of migraine pathophysiology and the mechanism of action of HBO over the past few years, further research is needed to expand our knowledge and create better treatments for patients with migraines.
DVM wrote the initial draft, and completed the final draft; DVM, BS, BL participated in the literature search; BS and BL participated in the proofread the initial draft. All authors read and approved the final manuscript for publication.
Conflicts of interest
Institutional review board statement
Prior to publication, the Committee of Oxygen Oasis Hyperbaric Wellness Center, USA approved this study.
Declaration of patient consent
Prior to publication of this article, informed consent was obtained from the patient this study focuses on.
Copyright transfer agreement
The Copyright License Agreement has been signed by all authors before publication.
Data sharing statement
Datasets analyzed during the current study are available from the corresponding author on reasonable request.
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Externally peer reviewed.
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| References|| |
Yildiz S, Uzun G, Kiralp MZ. Hyperbaric oxygen therapy in chronic pain management. Curr Pain Headache Rep
Niinikoski JH. Clinical hyperbaric oxygen therapy, wound perfusion, and transcutaneous oximetry. World J Surg
Tibbles PM, Edelsberg JS. Hyperbaric-oxygen therapy. N Engl J Med
Leach RM, Rees PJ, Wilmshurst P. Hyperbaric oxygen therapy. BMJ
Gill AL, Bell CN. Hyperbaric oxygen: its uses, mechanisms of action and outcomes. QJM
Fife CE, Eckert KA, Carter MJ. An update on the appropriate role for hyperbaric oxygen: indications and evidence. Plast Reconstr Surg
Jain KK. Textbook of Hyperbaric Medicine
. Cham: Springer International Publishing. 2018.
Weaver LK. Hyperbaric Oxygen Therapy Indications
ed. Durham, USA: Undersea and Hyperbaric Medical Society. 2014.
Bennett MH, Mitchell SJ. Emerging indications for hyperbaric oxygen. Curr Opin Anaesthesiol
Al-Waili NS, Butler GJ, Beale J, et al. Hyperbaric oxygen in the treatment of patients with cerebral stroke, brain trauma, and neurologic disease. Adv Ther
Mathieu D, Marroni A, Kot J. Tenth European Consensus Conference on Hyperbaric Medicine: recommendations for accepted and non-accepted clinical indications and practice of hyperbaric oxygen treatment. Diving Hyperb Med
Goadsby PJ, Lipton RB, Ferrari MD. Migraine--current understanding and treatment. N Engl J Med
Moskowitz MA. Neurogenic inflammation in the pathophysiology and treatment of migraine. Neurology
Charles A. The pathophysiology of migraine: implications for clinical management. Lancet Neurol
Wilson JR, Foresman BH, Gamber RG, Wright T. Hyperbaric oxygen in the treatment of migraine with aura. Headache
Celik O, Bay HH, Arslanhan A, et al. Effect of hyperbaric oxygen therapy on cerebral vasospasm: a vascular morphometric study in an experimental subarachnoid hemorrhage model. Int J Neurosci
Dodick DW. A phase-by-phase review of migraine pathophysiology. Headache
. 2018;58 Suppl 1:4-16.
Ferrari MD, Klever RR, Terwindt GM, Ayata C, van den Maagdenberg AM. Migraine pathophysiology: lessons from mouse models and human genetics. Lancet Neurol
Bosco G, Vezzani G, Mrakic Sposta S, et al. Hyperbaric oxygen therapy ameliorates osteonecrosis in patients by modulating inflammation and oxidative stress. J Enzyme Inhib Med Chem
Matchett GA, Martin RD, Zhang JH. Hyperbaric oxygen therapy and cerebral ischemia: neuroprotective mechanisms. Neurol Res
Myers DE, Myers RA. A preliminary report on hyperbaric oxygen in the relief of migraine headache. Headache
Eftedal OS, Lydersen S, Helde G, White L, Brubakk AO, Stovner LJ. A randomized, double blind study of the prophylactic effect of hyperbaric oxygen therapy on migraine. Cephalalgia
Bennett MH, French C, Schnabel A, Wasiak J, Kranke P, Weibel S. Normobaric and hyperbaric oxygen therapy for the treatment and prevention of migraine and cluster headache. Cochrane Database Syst Rev