(639) Intranasal Lidocaine Using DNAA for Treatment of Migraine

Authors: John Keun‐Sang Lee, Jefferson Pain and Rehabilitation Center, University of Pittsburgh Medical Center; Francis Bruce Marion, Jefferson Pain and Rehabilitation Center; L Otto Johnson, Therapeutic Clinical Laboratories, Inc, Therapeutic Drug Monitoring Laboratories, Madison Heights Hospital Lab Objectives: The purpose of this study was to investigate the effects of Intranasal Lidocaine HCL using a Deep Nasal Anesthetic Applicator (DNAA*) without actual sphenopalatine ganglion (SPG) block for the treatment of migraine headache. Setting: Community pain clinic. Patients: A total of 66 patients (45 women and 21 men) with a chief complaint of headaches, who fulfilled criteria of the International Headache Society for Migraine, participated. Intervention: To receive a maximum 0.05 ml of 26% and 19% solution of topical Lidocaine using Deep Nasal Anesthetic Applicator (DNAA) for sphenopalatine ganglion instillation. Main outcome measures: The primary outcome measure was at least 50% reduction of headache within 15 minutes after treatment. Secondary measures include reduction in nausea, photophobia side effects, relapse of headache, and change in headache and neck pain disability index. Results: Of 66 cases treated with intranasal sphenopalatine ganglion instillation of 26% Lidocaine solution using DNAA during attacks of varying intensities, 59 (89%) demonstrated at least a 50% reduction of headaches. Posttreatment intensity ratings significantly improved over pretreatment ratings. We measured the subjective improvement at 2 time intervals on a pain scale, 1 being the least and 10 being the worst. During the 15 minutes the improvement was 4.90 on average, at 60 minutes the improvement was 4.20 on average. The improvement was statistically significant. (<.001, in both measures in previous study with 4% of Intra Nasal Lidocaine instillation using DNAA). We also compared the improvement of DNAA with 26% solution of topical Lidocaine as compared to application of a 19% solution of topical Lidocaine. There was no relative difference in its effect. The therapeutic value between 26% solution and 19% solution of Lidocaine was as follows: P value = 0.303 in both measures of 6.8 days in 26% Lidocaine group and of 5.0 days in 19% Lidocaine group. Conclusion: Intranasal Lidocaine (26%) using noninvasive deep nasal anesthetic applicator (DNAA) (without actual SPG nerve block using needle) provides rapid relief of headache in approximately 89% of ambulatory patients with migraine headaches. Relapse of headache commonly occurs early after treatment, but intranasal instillation using DNAA might be more effective for longer relief of headache (average result of maximum duration 6.8 days) with minimal side effects as compared to 4% solution of intranasal Lidocaine spray (by indirect comparison). Further double‐blind, controlled study would be needed for better comparison. No significant difference was noted in results between 26% and 19% Lidocaine instillation using a DNAA for treatment of migraine headache. Research to establish therapeutic and toxicity levels indicates that up to 5 times instillation of 26% Lidocaine using DNAA is far below the therapeutic range (2–6 μg/ml) and toxicity level (above 9 μg/ml) in IM or IV injection of Lidocaine; (33 times instillation of 26% Lidocaine using DNAA was able to detect in up to 0.4 μg/ml in the blood level, which is far below minimal toxicity level).