Symptom-free status after prolonged suffering with refractory chronic migraine: A case report

Abstract

Migraine is ranked sixth among disability‑causing diseases in the world. Patients with chronic migraine suffer from headaches 15 days or more in a month. Refractory migraine patients fail to respond to conventional treatments even after avoiding all migraine triggers. These patients continue to suffer in the absence of any established cause and cure. A patient suffering from chronic refractory migraine for about 37 years presented with daily headache associated with symptoms of nausea, vomiting, phonophobia, and photophobia. The patient underwent 9 months Ayurvedic treatment, including initial three weeks of residential treatment. The patient reported a considerable reduction in Visual Analog Scale score, Migraine‑Induced Disability Assessment Score, duration/frequency of headache, consumption of analgesics, and improved general well‑being indicating the therapeutic efficacy of Ayurvedic treatment.KEYWORDS: Chronic Migraine, Refractory Migraine, Abhraka bhasma, Sitopaladi churna

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100 © 2021 Journal of Ayurveda Case Reports | Published by Wolters Kluwer - Medknow
Symptom‑free status after prolonged suffering
with refractory chronic migraine: A case report
Vaidya Balendu Prakash, G. D. Ramachandani1, Vaidya Shikha Prakash2,
Shakshi Sharma, Sneha Tiwari
Abstract:
Migraine is ranked sixth among disability‑causing diseases in the world. Patients with chronic
migraine suffer from headaches 15 days or more in a month. Refractory migraine patients fail
to respond to conventional treatments even after avoiding all migraine triggers. These patients
continue to suffer in the absence of any established cause and cure. A patient suffering from
chronic refractory migraine for about 37 years presented with daily headache associated with
symptoms of nausea, vomiting, phonophobia, and photophobia. The patient underwent 9 months
Ayurvedic treatment, including initial three weeks of residential treatment. The patient reported a
considerable reduction in Visual Analog Scale score, Migraine‑Induced Disability Assessment Score,
duration/frequency of headache, consumption of analgesics, and improved general well‑being
indicating the therapeutic efficacy of Ayurvedic treatment.
KEYWORDS: Chronic Migraine, Refractory Migraine, Abhraka bhasma, Sitopaladi churna
INTRODUCTION
Migraine is the most common form
of headache, which is characterized
by episodic headaches. In the absence
of any pathological or radiological tests,
the diagnosis of migraine is based on an
examination following the laid diagnostic
criteria of the International Headache
Society.[1] The disease may turn from episodic
to Chronic Migraine (CM), Refractory
Migraine (RM), and Medication Overuse
Headache (MOH). The chronic and refractory
state of migraine causes substantial disability
to the sufferers because of the unpredictable
and limited effects of conventional
treatment. Analgesics and Non‑Steroidal
Anti‑Inflammatory Drugs (NSAIDs)
remain the rst drug of choice for acute
management of mild-to-moderate migraine.
Ergot derivatives and/or triptans may also be
used as migraine specic medications.[2] In
case of chronic migraine, prophylaxis along
with acute management of migraine becomes
a necessity. Prophylactic treatment of CM
includes oral administration of beta-blockers,
anti-convulsants, calcium-channel blockers,
tricyclic anti-depressants, serotonin
antagonists, anti-hypertensives, and
anti-depressants.[3] Other preventive therapies
include, Onabotulinumtoxin A (OBT‑A)
injections and topiramate. Treatments
targeting Calcitonin Gene‑Related Peptide
are also emerging as prophylaxis for CM.[3]
However, these treatments have certain
adverse effects with the development of
MOH being the most troublesome one, as it
only worsens the pain condition.
Patients with chronic migraine experience
migraine symptoms for 15 days or more
in a month over a period of minimum
three months.[4] Refractory headaches are
Address for correspondence:
Dr. Vaidya Balendu Prakash,
VCPC Research Foundaon,
Prakash Villa, NH‑74, Danpur
Area, Rudrapur ‑ 263 153,
Uarakhand, India.
E‑mail: balenduprakash@
gmail.com
Submied: 12‑Feb‑2021
Revised: 15‑Sep‑2021
Accepted: 25‑Sep‑2021
Published: 14‑Dec‑2021
VCPC Research
Foundaon, Department
of Clinical Research,
Rudrapur, 1Department
of Medicine and Surgery,
SK Ramachandani
Orthopedic Hospital,
Kota, Rajasthan, 2Padaav
– Speciality Ayurvedic
Treatment Centre,
Dehradun, Uarakhand,
India
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DOI:
10.4103/jacr.jacr_14_21
How to cite this article: Prakash VB, Ramachandani GD,
Prakash VS, Sharma S, Tiwari S. Symptom-free status after
prolonged suering with refractory chronic migraine: A case
report. J Ayurveda Case Rep 2021;4:100-4.
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Case Report
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Prakash, et al.: Complete relief from refractory chronic migraine
Journal of Ayurveda Case Reports - Volume 4, Issue 3, July-September 2021 101
those that impact the quality of life despite modication
of triggers, lifestyle factors and adequate trails of acute and
preventive medicines with established efcacy. A patient is
considered to have refractory migraine when he/she fails
to respond to 3–4 adequate trials of preventive medicines,
alone or in combination, from at least 2 of 4 drug classes
including beta-blockers, anticonvulsants, tricyclics, and
calcium channel blockers, and also fails to respond to
adequate trials of abortive medicines, including both a
triptan and dihydroergotamine intranasal or injectable
formulations and either NSAIDs or combination of
analgesics, unless contraindicated.[5] MOH is headache
occurring on 15 or more days per month developing as a
consequence of regular overuse of acute or symptomatic
headache medication (on 10 or more, or 15 or more days
per month, depending on the medication) for more than
three months. MOH is described as headache present on
more than 15 days per month that has markedly worsened
during the period of medication overuse in patients with
regular overuse of one or more medicines for headache for
more than three months. Studies suggest that the mean time
of onset of MOH is 1.7 years for triptan users, 2.7 years
for patients taking ergots, and 4.8 years for those using
analgesics if taken regularly.[6]
The prevalence of migraine is on a rise globally. Around
12% of the world, population is affected by migraine.[7]
About 5%–8% of all migraineurs convert into CM patients
and about 5% develop RM, with the overall prevalence of
RM/CM at around 2%–3%.[8] MOH occurs in 0.5%–2.6%
population, while about 11%–70% Chronic migraine
patients have been reported to develop MOH.[8] The
substantial burden caused by the disease in association with
the limitations of available therapies lead patients toward
complementary and alternative treatment. Here, we present
a case of a 61‑year‑old orthopedic surgeon from Rajasthan,
India, who had developed refractory chronic migraine.
PATIENT INFORMATION
A 58‑year‑old man presented at our center in October
2017 with 37 years of history of headache. The patient
is nondiabetic, hypertensive and is a known case of
hypothyroidism. Both the conditions are well under control
with the help of allopathic medicines. He is vegetarian,
nonalcoholic, and nontobacco user. He had daily headaches
with Visual Analog Scale (VAS) score up to 9–10 and
Migraine‑Induced Disability Assessment Score (MIDAS)
about 66, indicating severe disability. On examination, he
was found to have Kapha‑pitta dominant pulse and pain in
right hypochondrium on deep palpation. He had bilateral
pedal edema.
The patient was initially diagnosed for migraine in
the year 1980 and was put on painkillers as and when
required. The migraine attacks continued with increased
frequency and intensity of pain. These attacks were
equally distributed between right and left temporal
region. The pain was throbbing in nature with severity 7-9
on VAS and was associated with vomiting at its peak.[9]
Factors that aggravated his migraine attacks were missing
of meals, travelling, exposure to sun, stress, exertion,
specic odors, lemon and lack of sleep. He only got relief
in pain after taking painkillers. The patient consulted a
neurologist in Udaipur and was advised betablockers,
tryptomers, calcium channel blockers, and painkillers (as
and when required). In 2002, he was advised OBT‑A
therapy by a leading Neurologist in Mumbai. He was
given Botulinum toxin A injections in forehead and neck
every six months. He had no severe attacks for about
six years but then resistance to the drug developed and
pain restarted.
In December 2013, the patient was admitted to a
multi-specialty modern hospital in Gurgaon with a
complaint of severe headache. He was diagnosed for
chronic migraine with severe medication overdose
headache. He was put on intravenous steroids for about
16 days and later oral steroids for three months. Occipital
nerve radiofrequency ablation was done. He had relief
in pain and the procedure was repeated after about
three months. However, he did not have much relief after
the second ablation and the attacks started to recur.
Table 1: Ayurvedic medicines prescribed
Medicine Dose Prescription
1Sootashekhara rasa (250 mg)
Abhraka bhasma (62.5 mg)
Sitopaladi rasa (500 mg)
1x3 Mix the powders in the specied quantities in a spoon by adding quantity sufcient
honey and take at 6:30 am, 12:30 pm and 6:30 pm.
2Punarnava mandora (fortied with 8 herbs) 1x4 At 7 am, 11 am, 3 pm and 7 pm without water.
3Narikela lavana (1 gm) 1x2 Mix the powder in 200 gm of curd and 50 ml of potable water and consume freshly
at 7 am and 5 pm.
4Rasona vati (500 mg) 2x3 Chew two tablets after breakfast, lunch and dinner with hot water.
5Godanti mishrana (500 mg) 1x1 Take powder at bedtime without water.
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Prakash, et al.: Complete relief from refractory chronic migraine
102 Journal of Ayurveda Case Reports - Volume 4, Issue 3, July-September 2021
Table 2: Daily diet and lifestyle prescribed
Particulars Advice
Diet 3 meals and 3 snacks (total 1800–2200 calorie)
Lifestyle 8 h of sleep at night, avoid sleeping during the day,
20 min walk in the morning and evening
The patient consulted a leading neurologist at a
multi‑specialty modern hospital in Mumbai in August
2014 and was declared to have intractable (refractory)
migraine. Bilateral occipital nerve stimulation and octad
electrode implantation along both greater occipital nerves
with Internal Pulse Generator (IPG) insertion was done.
The patient did not experience complete relief and also
complained of mild pain and discomfort at the IPG site due
to the formation of keloid. In April 2016, during follow‑up
visit to the hospital in Mumbai, the implant was removed.
Since then, he again started having attacks of migraine
and continued to manage the pain with painkillers until
October 2017.
THERAPEUTIC INTERVENTION
The patient was examined and admitted for supervised
indoor treatment for initial three weeks. He was put on
Ayurvedic treatment [Table 1]. Tea, coffee, aerated drinks,
rened our, packaged food items, and reheated food were
completely stopped in his diet. He was advised 1800–2200
Calorie daily balanced diet, divided into three meals and
three snacks with eight hour of undisturbed sleep at
night [Table 2]. He was also prescribed Nasya and Shirodhara
during the indoor treatment. A combination of powders of
Sootashekhara rasa,[10] Abhraka bhasma,[11] Sitopaladi churna,[12]
Punarnava mandora (fortified with 18 herbs), Narikela
lavana,[13] Rasona vati[13] and Godanti mishrana (250 mg tablet
containing Godanti bhasma, Rasadi vati, Jawaharmohra pishti,
Chandra arka, and Gojihva arka).[13] At discharge, the patient
was advised to continue the same treatment with all the diet
and lifestyle related advices. The treatment was continued
for nine months.
TIMELINE
The detailed timeline of the case is depicted in Table 3.
FOLLOW‑UP AND OUTCOME
The patient started to show improvement within the
initial three week of treatment. His VAS score, number
of headache days and drug consumption to control
symptoms dropped down gradually [Graph 1]. Marked
effect was seen on MIDAS score [Graph 2]. Associated
symptoms, including nausea, vomiting, phonophobia,
and photophobia disappeared completely after 30 days
of treatment. No adverse effects of the treatment were
reported. After two years of treatment, the patient still
reported satisfaction improvement. He was experiencing
occasional pain with minimal intensity (VAS = 1) of
headache that subsides on its own.
DISCUSSION
CM, RM, and MOH are progressive stages of Migraine.
The conventional treatment is aimed at bringing maximum
relief in symptoms and minimizing the acute exacerbations
of migraine attacks. The patients are given prophylactic
and abortive medicines, which may cause moderate to
severe side effects. The presented case is a classic case of
migraine. Episodic headaches started in his early twenties
and gradually converted into chronic migraine, refractory
migraine, and medication overuse headache. In this case,
migraine and its treatment had adversely affected the
patient’s personal, professional, and social life. The regular
use of intravenous painkillers had damaged his veins so
badly that he was not able to wear any footwear because
of pedal edema. In a desperate attempt to get rid of the
disease, the patient had also undergone OBT‑A therapy and
occipital nerve radiofrequency ablation surgery, but there
was not much effect. Although the patient had established
diagnosis of CM/RM/MOH, he was evaluated on Ayurvedic
principles of diagnosis, including Darshanam (~visual),
Sparshanam (~palpation), and Prashnam (~questioning)
followed by Ashtavidha parikshana (~examination of eight
factors including Nadi, Mutra, Mala, Jihwa, Sabdam, Sparsham,
Drik, and Akrithi). He was found to have Pitta‑kapha dominant
pulse. There were signs of acid-alkali imbalance and delayed
digestion with lots of atulence and abdominal distension.
He had pain on palpation in the right hypochondrium and
tenderness in the right iliac fossa.
Ayurveda emphasizes on the balance of Vata‑pitta‑kapha
for healthy state of body. There are laid guidelines related
to daily routine, diet and lifestyle in Ayurveda depending
on place, weather, and age of individual. These practices
are diminished these days due to the pressure of today’s
world, especially in big cities. Here, the patient was put
on Ayurvedic treatment after stopping all conventional
medicine. He was prescribed a disciplined regime of sleep,
diet, and water intake along with Ayurvedic medicines.
The patient reported congestion and headache on waking
up sometimes, indicating sinusitis-related migraine.
Hence, he was prescribed Nasya using eight drops of
cold compressed mustard oil in each nostril for 21 days.
Being a senior medical professional himself, he was quite
stressed with his chronic migraine. Hence, Takra shirodhara
was advised for 8 days as he was sensitive to the smell of
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Prakash, et al.: Complete relief from refractory chronic migraine
Journal of Ayurveda Case Reports - Volume 4, Issue 3, July-September 2021 103
Graph 1: Impact of Ayurvedic treatment on VAS score, headache days
and drug consumption. Headache days denotes number of days when
headache occurred in a month and drug consumptions denotes number
of painkillers taken for relief from headache in a month
oils. There was gradual effect on both the intensity and
frequency of pain with overall improvement in general
well-being.
Migraine was ascribed by Tissot as a result of reexes
of the gall bladder, stomach, and uterus.[14] Later on, it
was considered as supraorbital neurological disorder.
The Ayurvedic diagnosis and treatment is very similar
to the approach of Tissot. The treatment is based on a
hypothesis that the symptoms of migraine are similar
to that of Shleshma pitta. The said hypothesis is further
strengthened by the fact that the prescribed Ayurvedic
formulations, Sootashekara rasa, Abhraka bhasma and
Sitopaladi churna, prescribed are Pitta shamak and help in
balancing of pH within the gut. Narikela lavana is used
to reduce Pittashaya shotha (~inammation of the gall
bladder) and helps in the ow of bile in the gut. Rasona
vati is well known for Vatanulomana (~enhancing the
movement of gases downward) in the body. Godanti
mishrana is used for treating malaise, headache and is
Pitta shamaka. Thus, all medicines were given to lower
Pitta, reduce inammation of the gall bladder and gut
and improve the peristalsis of the intestine and colon.
None of the formulations have any ingredient with
properties to relieve pain. A pharmacological study on
these formulations has also indicated toward the said
hypothesis as these formulations have no analgesic,
anti‑inammatory, anti‑depressant or anti‑epileptic effect
and have no effect on neurobehavioral parameters (data
on le). This further strengthens the stated hypothesis as
these medicines could play a role in alleviating Shleshma
pitta and abdominal symptoms only and had no effect
on pain. Signicant improvement in this chronic case
reveals the usefulness of Ayurveda procedures, the
management strategies in such complex conditions.
Ayurvedic treatment was well tolerated by the patient
without any adverse events. The observation of the study
indicates that Ayurveda has a signicant and sustainable
effect in the prevention of migraine.
CONCLUSION
The case report indicates the therapeutic efficacy of
Ayurvedic treatment in bringing notable long‑term relief
in Chronic and Refractory Migraine.
Declaration of patient consent
Authors certify that they have obtained patient consent
form, where the patient/caregiver has given his/her
consent for reporting the case along with the images and
other clinical information in the journal. The patient/
caregiver understands that his/her name and initials will
not be published and due efforts will be made to conceal
his/her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Graph: 2: Impact of Ayurvedic treatment on Migraine Induced Disability
Assessment Score
Table 3: Timeline of the case
1Patient (gender, age) Male, 58 years old
2Final Diagnosis Refractory Chronic Migraine
3Symptoms Daily headaches, nausea, vomiting, phonophobia, photophobia
4 Medications Ayurvedic Treatment
Sootashekhara rasa (250 mg) + Abhraka bhasma (62.5 mg) + Kamadudha rasa (500 mg); Modied Punarnava mandoor
(1 gm); Narikela lavana (1 gm); Rasona vati (500 mg); Godanti mishran (500 mg)
5Clinical Procedure Nine months long Ayurvedic treatment
Three weeks indoor treatment under supervision of treating doctor, including the procedures of Nasya and takra shirodhara
once a day for twenty-one and eight days, respectively.
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Prakash, et al.: Complete relief from refractory chronic migraine
104 Journal of Ayurveda Case Reports - Volume 4, Issue 3, July-September 2021
Conflicts of interest
There are no conicts of interest.
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