8/6/18. Patient Experience. effective management of Chronic Migraine and Occipital Neuralgia in the Post 9/11 Combat Veteran

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1 8//8 Patient Experience Validation of practice based evidence for effective management of Chronic Migraine and Occipital Neuralgia in the Post 9/ Combat Veteran Karen Williams,MSN, RN, FNP-BC Neurology/Headache Clinic Central Texas Veterans Health Care System yo male with a history of refractory headaches increased after 00 deployment Started in 99 with parachute jump, hard landing, hit head to the left, with Loss of Consciousness (LOC)- 00- Improvised explosive Device (IED) blast with LOC Described as Left hemi-cranial throbbing/aching associated with photophobia/phonophobia, Nausea/Vomiting & worse with exertion. Rated as / Occurring - times per month lasting 3- days ~ (up to days per month debilitating headache, plus a daily posterior headache) Overview of the Headache Population Conceptual Framework The Headache clinic was established in November 03 Patient population: Refractory headache patients- most have failed Primary Care treatments, many have also failed Neurology, all seeking alternatives Common types of headache- Migraine, Occipital Neuralgia, Tension, Cervical degeneration Common co-occurring diagnosis- prior hx of head and/or neck injury, PTSD, Insomnia, Anxiety/Depression, Musculoskeletal pain, The Headache Clinic utilizes a Chronic Care Model Incorporate multiple modalities: Traditional and Alternative Medication Botox Occipital blocks Acupuncture Cefaly/Alpha-stim Relaxation techniques Aromatherapy (Peppermint oil) Patient education (continual) Study Purpose Headache clinic utilizes: o Onabotulinum A (BOTOX) every weeks o Occipital blocks every -8 weeks as needed o Treating combat veteran with a history of: traumatic brain injury(tbi) neck trauma/whiplash with chronic migraine (CM) occipital neuralgia o Based on the available evidence /anecdotally this seemed to be very effective o Validation through empirical practice based evidence was needed

2 8//8 Study Disclaimer This study: Was been reviewed and approved by the Central Texas Veterans Health Care System (CTVHCS) Institutional Review Board and University of Alabama at Tuscaloosa This material is the result of work supported by resources at the Central Texas Veterans Health Care System Does not necessarily express the views of the Department of Veterans Affairs or the United States Government nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government Background CM in the post 9/ combat veteran with a history of TBI- is 0% or more: even after years of treatment (Couch & Stewart 0; Patil et al., 0) General population CM rate is - % (Munakata et al., 009) CM causes: reduced work and quality of life, increase in ER and primary visits (Munakata et al., 009) Young population: average age of post 9/ combat with CM 9-30 years of age (Altalib et al., 0) Knowledge Gap Current treatments- medications for prevention (Topiramate) and Onabotulinum Toxin A (BOTOX)(Yerry, Kuehn, & Finkel, 0) Treatments failure- wear off of Botox before weeks and do not fully address the occipital neuralgia Occipital neuralgia is common after traumatic brain injury (TBI)/neck trauma and may be part of the CM (Ducic, Sinkin, & Crutchfield, 0; Zaremski, Herman, Clugston, Hurley, & Ahn, 0) Occipital Blocks have been an effective treatment for occipital neuralgia and short term relief of CM (Cuadrado et.al, 0; Gul, Ozon, Karadas, Koc, &; Inan, 0) (Onabotulinumtoxin A Botox ) Injection Paradigm 3 injections into 7 muscle groups Blumenfeld et. al, Headache 0;0:0-8. Cutaneous innervation of the head and neck The sensory distribution of the trigeminal nerve (cranial nerve V) and its three divisions (V, V, V3) are show along with branches of the cervical spinal nerves that innervate cutaneous regions of the head and neck. Occipital Nerve Anatomy Image courtesy of UpToDate

3 8//8 Occipital Block Injection Sites Methodology GON aiming slightly up maintaining a subcutaneous course LOC aiming lateral and up, maintaining a subcutaneous course Occipital block consisted of to ratio of % Lidocaine & 0.% Bupivacaine, ml into the greater and 0. ml into the lesser 3 Retrospective review of post 9/ combat veterans seen in the headache clinic between Jan, 0- Dec 3, 0 History of TBI or neck trauma/whiplash Findings of CM & Occipital Neuralgia Treated with Botox and Occipital Blocks 8 patient charts reviewed > 37 Dx w/cm & Occipital neuralgia > 7 excluded (did not fit all the criteria) > 30 were included Data Collection Number of self-reported headache days per month (8 days) o The month prior to treatment in the headache clinic o months after treatment in the headache clinic o Mean and 9% confidence interval for # of Headache days/month for pre and post intervention for each subject was computed o Binomial mixed regression model- to determine if the mean # of headache days is significantly lower post intervention Dependent Variables: headache days per month (8 days) Independent variables: age, gender, head or neck trauma, headache types (migraine, tension, occipital neuralgia, medication overuse), comorbid diseases (mood disorders of anxiety, depression or PTSD, musculoskeletal pain, insomnia), prior headache treatments and treatments in the headache clinic of Botox and occipital blocks 0% % 7% Number of Veterans in each age range 8 3% Veteran ages ranged 0 from 7 to. years of age. [7, 3.] (3.,.] (., 8.3] 80% were between the ages of 7 and. years Patient age PRIOR PREVENTATIVE MEDICATION TREATMENTS Topiramate Divalproex TCA Inderal Verapamil Gabapentin Number of Veterans Year of Headache Onset Headaches started after the head or neck trauma 9 Number in the graphic represents the number of veterans who had taken the medication for migraine prevention prior to treatment in the headache clinic. 3 veterans had trials of 3 or more medications

4 8//8 Gender Distribution of Patients Treated 30 Comorbid Conditions 0 Veteran 0 # of Males # of Females Some patients were diagnosed with PTSD & Anxiety or Depression PTSD = Post-traumatic Stress Disorder MSK = Musculoskeletal Disorder 0 PTSD Anxiety Depression MSK Insomnia Medical Diagnosis Results 30 Pre-Post Headache Frequency Mean number of headache days in the month prior to treatment was. (.0,.7)* Mean number of headache days in the month post-treatment was.9 (9.7,.)* Mean difference in number of headache days (pre-treatment minus post-treatment) was. (8.,.)* Findings were clinically and statistically significant Number of Headache days 0 *Numbers in parenthesis are the 9% Confidence Interval Headaches Pre Veterans Headaches Post * patients did not have a reduction in number of headache days, but did have a reduction in severity of headaches Limitations/Needs Results are promising in treating CM and Occipital neuralgia with Botox and Occipital Blocks Limitations: Inability to have treatment and control group small sample size (N=30) self report for only one month pre and post treatment Needs: Long term study Larger cohort controlled for confounders Additional studies for CM/Occipital neuralgia treatment in the veteran population Final Thoughts Post 9/ combat veterans, with a history of TBI or neck trauma/whiplash with findings of CM and occipital neuralgia, who have not had satisfactory relief of their CM with conventional medical treatment, may have a reduction in the number of days of headache after treatment with occipital blocks and Botox In other words: it may reduce the headache burden and improve quality of life

5 8//8 Karen Williams Central Texas Veterans Health Care System 90 Veterans Memorial Drive Temple, TX 70 Altalib, H. H., Fenton, B. T., Sico, J., Goulet, J. L., Bathulapalli, H., Mohammad, A.,... Haskell, S. (0). Increase in migraine diagnoses and guideline-concordant treatment in veterans, Cephalalgia: An International Journal of Headache. Advance on Line Publication. doi: Blumenfeld, A, Silberstein SD, Dodick DW, Aurora SK, Turkel CC, Binder WJ. Method of injection of OnabotulinumtoxinA for chronic migraine: A safe, well-tolerated, and effective treatment paradigm based on the PREEMPT clinical program. Headache: The Journal of Head and Face Pain. 0;0(9): doi:./j x Couch, J. R., & Stewart, K. E. (0). Headache prevalence at years after deployment-related traumatic brain injury in veterans of Iraq and Afghanistan wars and comparison to controls: A matched case-controlled study. Headache: The Journal of Head and Face Pain, (), 0-. doi:./head.837 Cuadrado, M. L., Aledo-Serrano, A., Navarro, P., Lopez-Ruiz, P., Fernandez-de-Las-Penas, C., Gonzalez-Suarez, I.,... Fernandez-Perez, C. (0). Short-term effects of greater occipital nerve blocks in chronic migraine: A double-blind, randomised, placebo-controlled clinical trial. Cephalalgia : An International Journal of Headache, doi:03339 Ducic, I., Sinkin, J. C., & Crutchfield, K. E. (0). Interdisciplinary treatment of post-concussion and post-traumatic headaches. Microsurgery, 3(8), doi:.0/micr.03 DoD Worldwide Number for TBI. (0, Aug). Retrieved from mil/files/tbinumbers/dod-tbi-worldwide-totals_000-0_feb-7-07_v.0_ pdf Finkel, A. G., Yerry, J. A., Klaric, J. S., Ivins, B. J., Scher, A., & Choi, Y. S. (0). Headache in military service members with a history of mild traumatic brain injury: A cohort study of diagnosis and classification. Cephalalgia: An International Journal of Headache. Advance online publication. doi:03338 Gul, H. L., Ozon, A. O., Karadas, O., Koc, G., & Inan, L. E. (0). The efficacy of greater occipital nerve blockade in chronic migraine: A placebo-controlled study. Acta Neurologica Scandinavica, n/a. doi:./ane.7 Headache Classification Committee of the International Headache Society, (IHS). (03). The international classification of headache disorders, 3rd edition (beta version). Cephalalgia : An International Journal of Headache, 33(9), doi:.77/ Management of Concussion-mild Traumatic Brain Injury (mtbi). Retrieved from Healthquality.va.gov/guidelines/Rehab/mtbi Munakata, J., Hazard, E., Serrano, D., Klingman, D., Rupnow, M. F. T., Tierce, J.,... Lipton, R. B. (009). Economic Burden of Transformed Migraine: Results from the American Migraine Prevalence and Prevention (AMPP) study. Headache: The Journal of Head and Face Pain, 9, doi:./j x National Center for Veterans Analysis and Statistics. (0, May). Profile of Post - 9/ Veterans: 0. Retrieved from Patil, V. K., St. Andre, J. R., Crisan, E., Smith, B. M., Evans, C. T., Steiner, M. L., & Pape, T. L. (0). Prevalence and treatment of headaches in veterans with mild traumatic brain injury. Headache: The Journal of Head & Face Pain,, -. doi:./j x Theeler, B. J., & Erickson, J. C. (009). Mild head trauma and chronic headaches in returning US soldiers. Headache: The Journal of Head and Face Pain, 9, 9-3. doi:./j x Theeler, B. J., Flynn, F. G., & Erickson, J. C. (0). Chronic daily headache in U.S. soldiers after concussion. Headache: The Journal of Head and Face Pain,, doi:./j x Vos, T., Flaxman, A. D., Naghavi, M., Lozano, R., Michaud, C., Ezzati, M.,... Atkinson, C. (03). Years Lived with Disability (YLDs) for Sequelae of 89 Diseases and Injuries 990-0: A Systematic Analysis for the Global Burden of Disease Study 0. Lancet, 380 North American Edition (989), 3-9. doi:./s00-73()79-

6 8//8 Yerry, J. A., Kuehn, D., & Finkel, A. G. (0). Onabotulinum toxin A for the treatment of headache in service members with a history of mild traumatic brain injury: A cohort study. Headache: The Journal of Head & Face Pain,, doi:./head.9 Zaremski, J. L., Herman, D. C., Clugston, J. R., Hurley, R. W., & Ahn, A. H. (0). Occipital neuralgia as a sequela of sports concussion: A case series and review of the literature. Current Sports Medicine Reports (American College of Sports Medicine), (), -9. doi:.9/jsr