A novel self treatment technique for cluster headache
Eve, Le Cong, M and Kaul V
Abstract : We describe a novel self treatment technique of instilled nasal lidocaine jelly to treat refractory cluster headache at home.
A 37 year old female ICU registered nurse (lead author of this report) with a long history of cluster headaches developed an acute attack characterised by severe right sided supraorbital headache with associated right sided lacrimation and nausea. She initiated her usual prescribed treatments with nasal triptans, aspirin and acetaminophen. This regimen had little alleviating effect. She called her physician on day three of the continuous headache and was advised to sleep it off and try achieving relief by using prochlorperazine.
Having had a previous excellent response to nasal lidocaine applied by a physician 2 months ago, she decided to trial nasal lidocaine jelly that she had available at home. As the optimal site of lidocaine application is the posterior nasopharynx where the sphenopalatine ganglion is located , she had used a long swab stick applicator but this was unavailable to her at time of this event. The lidocaine jelly was packaged in a 5 ml tube with 100 mg of lidocaine per tube in 2% concentration . It was determined that 100 mg would be the maximum daily safe limit for nasal application.
Initially she applied a small amount of the jelly to a short cotton tipped applicator and attempted to pass this to the posterior nasopharynx on the same side as the headache. Due to the short length of the cotton applicator she felt this was inadequate to effectively apply the lidocaine close to the SPG . Recalling her nursing practice of using lidocaine jelly for nasal endoscopy and bronchoscopy, she snorted the jelly into her right nostril until she could feel and taste it in the back of her throat while keeping her head extended. She then lay semi-reclined with her neck extended to allow the lidocaine to migrate posteriorly into nasopharynx (3). A total of one tube or 100 mg of lidocaine was used. After 50 minutes, her headache had completely resolved. 1 week later, the cluster headache has not recurred despite taking no further migraine medications.
Nasal lidocaine treatment for acute cluster headache is well described with debatable success (1) in the medical literature. 1 ml lidocaine is typically applied as a 4% to 10% (2) aqueous solution in form of a spray (3) or soaked onto a long cotton swab applicator and applied to the posterior nasal wall unilateral to the headache. The use of the less concentrated 2% lidocaine jelly is unique as well as the application technique, including confirming adequate migration of the drug by being able to taste it.
Morgan, Anna, and Vanessa Jessop. “Best BETs from the Manchester Royal Infirmary. BET 2: should intranasal lidocaine be used in patients with acute cluster headache?.” Emergency medicine journal: EMJ 30.9 (2013): 769-770.
May, Arne. “Cluster headache: pathogenesis, diagnosis, and management.” The Lancet 366.9488 (2005): 843-855.
Robbins, Lawrence. “Intranasal lidocaine for cluster headache.” Headache: The Journal of Head and Face Pain35.2 (1995): 83-84.
— Minh Le Cong (@ketaminh) March 10, 2018
All pictures above contributed with consent by Mitochondrial Eve @BrowofJustice. Thankyou Eve for sharing to help others similarly afflicted with cluster migraines!