Aseptic Packaging. Content Introduction What is Aseptic? Aseptic Packaging Advantages Limitations.
Subcutaneous Sumatriptan Relieved Migraine-Like Headache in Two Adolescents With Aseptic Meningitis
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5. Rossi S, Giannini F, Cerase A, et al. Uncommon findings in idiopathic hypertrophic cranial pachymeningitis. J Neurol. 2004;251:548-555. 6. Ruiz-Sandoval JL, Bernard-Medina G, Ramos-Gómez EJ, et al. Idiopathic hypertrophic cranial pachymeningitis suc- cessfully treated with weekly subcutaneous methotrexate. Acta Neurochir (Wien). 2006;148:1011-1014. 7. Martin N, Masson C, Henin D, Mompoint D, Marsault C, Nahum H. Hypertrophic cranial pachymeningitis: Assess- ment with CT and MR imaging. AJNR Am J Neuroradiol. 1989;10:477-484. 8. Song JS, Lim MK, Park BH, Park W. Acute pachymenin- gitis mimicking subdural hematoma in a patient with pol- yarteritis nodosa. Rheumatol Int. 2005;25:637-640. Subcutaneous Sumatriptan Relieved Migraine-Like Headache in Two Adolescents With Aseptic Meningitis Sergey Prokhorov, MD; Shefali Khanna, MD; Deepthy Alapati, MD; Sai Lakshmi Pallimalli, MD Sumatriptan was developed as an agent for the treatment of acute migraine. However, sumatriptan may alleviate not only migraine headache, but also headache of subarachnoid hemorrhage and meningitis. We report 2 patients whose migraine-like headache on presentation was relieved by subcutaneous sumatriptan. Later, both patients were diagnosed with aseptic meningitis. Key words: headache, aseptic meningitis, sumatriptan CASE REPORTS Patient 1.—A 13-year-old boy was admitted to the hos- pital with a 2-day history of progressive retro-ocular and global pounding headache, associated with dizziness, pho- tophobia, nausea, and intolerance of regular physical activ- ity. Within this period of 2 days, he vomited 3 times. The onset of this headache was gradual. On the second day, the intensity of headache had increased up to 8 out of 10 on pain scale. The patient had remained afebrile, without any other signs of acute illness. Medical history included infrequent episodes of head- ache since 7-8 years of age. These headaches were not severe; Motrin and sleep relieved them completely. The patient’s parents and older sister had a history of episodic headaches. On examination, the patient had nontoxic appearance; his neurological examination was without abnormal findings. Computerized tomography scan of the head did not reveal any intracranial lesions. Protracted migraine attack was initially considered in the emergency room. Ibuprofen 400 mg and intravenous metoclopramide 10 mg were given to the patient 2 times, 3 hours apart, with very modest and short-lasting headache relief. Three hours later, when headache intensity was 7/10, the patient received sumatriptan 6 mg subcutaneously; 30 minutes later, the patient reported complete relief of head- ache along with all other associated symptoms. The next morning, the patient had fever 101.7°F (38.7°C) with tran- sient retro-ocular pain of 4/10 on pain scale. Mild neck rigidity was noticed on examination. Lumbar puncture was performed with reported cerebrospinal fluid results compat- ible with viral meningitis: white blood cell (WBC) – 547, lymph – 96%, neutrophils – 4%, protein – 34 mg/dL, glucose – 65 mg/dL, gram stain – negative, cerebrospinal fluid (CSF) culture – negative. The patient was discharged in 2 days and was headache-free at the time of discharge and on follow-up visit one week later. Patient 2.—A 12-year-old girl was admitted to the hos- pital with her first headache persisting for 2 days. Clinical features included a severe frontal pounding headache, asso- ciated with neck pain, photophobia, nausea, and vomiting. On the day of admission, the headache had worsened to 9 out of 10 on pain scale. The patient’s attempts to sit up or walk precipitated vomiting. Ibuprofen and Tylenol did not From the Department of Pediatrics, Lincoln Medical and Mental Health Center, Bronx, New York, and Weill Medical College of Cornell University, New York, NY, USA. Address all correspondence to S. Prokhorov, Department of Pediatrics, Lincoln Medical and Mental Health Center, Bronx, New York, and Weill Medical College of Cornell University, New York, NY, USA. Accepted for publication March 28, 2008. Conflict of Interest: None Headache 1235
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Transcript of Subcutaneous Sumatriptan Relieved Migraine-Like Headache in Two Adolescents With Aseptic Meningitis
5. Rossi S, Giannini F, Cerase A, et al. Uncommon findings inidiopathic hypertrophic cranial pachymeningitis. J Neurol.2004;251:548-555.
6. Ruiz-Sandoval JL, Bernard-Medina G, Ramos-Gómez EJ,et al. Idiopathic hypertrophic cranial pachymeningitis suc-cessfully treated with weekly subcutaneous methotrexate.Acta Neurochir (Wien). 2006;148:1011-1014.
7. Martin N, Masson C, Henin D, Mompoint D, Marsault C,Nahum H. Hypertrophic cranial pachymeningitis: Assess-ment with CT and MR imaging. AJNR Am J Neuroradiol.1989;10:477-484.
8. Song JS, Lim MK, Park BH, Park W. Acute pachymenin-gitis mimicking subdural hematoma in a patient with pol-yarteritis nodosa. Rheumatol Int. 2005;25:637-640.
Subcutaneous Sumatriptan Relieved Migraine-Like Headachein Two Adolescents With Aseptic Meningitis
Sergey Prokhorov, MD; Shefali Khanna, MD; Deepthy Alapati, MD; Sai Lakshmi Pallimalli, MD
Sumatriptan was developed as an agent for the treatment of acute migraine. However, sumatriptan may alleviate not onlymigraine headache, but also headache of subarachnoid hemorrhage and meningitis. We report 2 patients whose migraine-likeheadache on presentation was relieved by subcutaneous sumatriptan. Later, both patients were diagnosed with aseptic meningitis.
Key words: headache, aseptic meningitis, sumatriptan
CASE REPORTSPatient 1.—A 13-year-old boy was admitted to the hos-
pital with a 2-day history of progressive retro-ocular andglobal pounding headache, associated with dizziness, pho-tophobia, nausea, and intolerance of regular physical activ-ity. Within this period of 2 days, he vomited 3 times. Theonset of this headache was gradual. On the second day, theintensity of headache had increased up to 8 out of 10 onpain scale. The patient had remained afebrile, without any
other signs of acute illness.
Medical history included infrequent episodes of head-ache since 7-8 years of age. These headaches were notsevere; Motrin and sleep relieved them completely. Thepatient’s parents and older sister had a history of episodicheadaches. On examination, the patient had nontoxicappearance; his neurological examination was withoutabnormal findings. Computerized tomography scan of thehead did not reveal any intracranial lesions.
Protracted migraine attack was initially considered inthe emergency room. Ibuprofen 400 mg and intravenousmetoclopramide 10 mg were given to the patient 2 times, 3hours apart, with very modest and short-lasting headacherelief. Three hours later, when headache intensity was 7/10,the patient received sumatriptan 6 mg subcutaneously; 30minutes later, the patient reported complete relief of head-ache along with all other associated symptoms. The nextmorning, the patient had fever 101.7°F (38.7°C) with tran-sient retro-ocular pain of 4/10 on pain scale. Mild neckrigidity was noticed on examination. Lumbar puncture wasperformed with reported cerebrospinal fluid results compat-ible with viral meningitis: white blood cell (WBC) – 547,lymph – 96%, neutrophils – 4%, protein – 34 mg/dL, glucose– 65 mg/dL, gram stain – negative, cerebrospinal fluid (CSF)culture – negative.The patient was discharged in 2 days andwas headache-free at the time of discharge and on follow-upvisit one week later.
Patient 2.—A 12-year-old girl was admitted to the hos-
pital with her first headache persisting for 2 days. Clinicalfeatures included a severe frontal pounding headache, asso-ciated with neck pain, photophobia, nausea, and vomiting.On the day of admission, the headache had worsened to 9out of 10 on pain scale. The patient’s attempts to sit up orwalk precipitated vomiting. Ibuprofen and Tylenol did not
From the Department of Pediatrics, Lincoln Medical andMental Health Center, Bronx, New York, and Weill MedicalCollege of Cornell University, New York, NY, USA.
Address all correspondence to S. Prokhorov, Department ofPediatrics, Lincoln Medical and Mental Health Center, Bronx,New York, and Weill Medical College of Cornell University,New York, NY, USA.
Accepted for publication March 28, 2008. Conflict of Interest: None
Headache 1235
relieve the headache. The patient had remained afebrile,
without any other signs of acute illness.
She had recent contact with 2 siblings who were seen inthe emergency department 2 days earlier with fever,abdominal pain, diarrhea, and skin rash. Medical history
was unremarkable.
On examination, the patient was awake, alert, and withnontoxic appearance. She refused to sit up, and her face wascovered with a blanket due to photophobia.The intensity ofheadache was 9 out of 10 on pain scale. No focal abnormali-ties were found on neurological examination. Fundoscopy
revealed sharp disc margins.The patient had nuchal rigidity.
In this patient, viral meningitis was suspected andlumbar puncture was imperative. Sumatriptan 6 mg wasinjected prior to lumbar puncture to relieve the headache.In 25 minutes, the patient reported significant relief ofheadache to 2 out of 10. She denied neck pain, photophobia,and nausea. Meningeal signs were negative. The patientwas pleasant and preferred a sitting position during
reexamination.
Lumbar puncture was performed with reported CSFfindings compatible with the diagnosis of viral meningitis:WBC – 127, lymph – 65%, segm – 9% mon – 23%;protein – 31 mg/dL, glucose – 64 mg/dL, gram stain –
negative, CSF culture – negative.
The patient was headache-free during the rest of theday. The next day, she had one episode of low-grade fever
with transient headache which subsided spontaneously.
On the third day of hospitalization, the patient wasdischarged home in a stable and headache-free condition.
DISCUSSIONSubcutaneous sumatriptan was added to the list of
migraine abortive agents in pediatric patients1-3 after 2open-label studies4,5 suggested that subcutaneous sumatrip-tan was effective and well-tolerated in alleviating migraineheadache in children.
Both presented patients did not meet the InternationalHeadache Society criteria for episodic migraine as theyexperienced severe and protracted headache attack for thefirst time in their life. Use of “off-label” subcutaneoussumatriptan relieved migraine-like headache attributed tolymphocytic meningitis. There has been only one casereport on significant headache-relieving effect of naratrip-tan in young adults with aseptic lymphocytic meningitis.6
As in patients with acute migraine, the headache-relieving effect of subcutaneous sumatriptan in asepticmeningitis can be based on 2 experimentally studiedmechanisms of the actions of triptans. Sumatriptanblockades presynaptic meningeal inflammation, contractsmeningeal vessels, and inhibits transmission of nociceptiveimpulses from inflamed meninges to the trigeminal-nuclearcomplex.7 In meningitis, sumatritan presumably can pen-etrate blood–brain barrier and bind to 5HT1B/1D receptorin the periaqueductal grey matter activating descendingpain-modulating pathway to the trigeminal nucleus caudaliswith an inhibition of meningeal nociceptive input.8 These 2cases indicate that the powerful headache-relieving effectof subcutaneous sumatriptan may lead to misdiagnosis ofmeningitis.
CONCLUSIONThe implication of this report in clinical practice is
that subcutaneous sumatriptan seems to have the potentialto be therapeutically helpful for migraine-like headaches inchildren with aseptic meningitis.
Identification of the cause of headache should remainthe priority in the management of patients with headache.The symptomatic treatment with sumatriptan should beinitiated only after the final diagnosis is established.
REFERENCES
1. Maria BL. Current Management in Child Neuology, 3rd ed.Hamilton/London: BC Decker Inc.; 2005.
2. Lewis D. Pediatric migraine. Pediatr Rev. 2007;28:43-53.3. Kabouche MA, Linder SL. Acute treatment of pediatric
headache in the emergency department and inpatient set-tings. Pediatr Ann. 2005;34:466-471.
4. MacDonald JT. Treatment of juvenile migraine with subcu-taneous sumatriptan. Headache. 1994;34:581-582.
5. Linder SL. Subcutaneous sumatriptan in the clinical setting:The first 50 consecutive patients with acute migraine in apediatric neurology office practice. Headache. 1996;36:419-422.
6. Bartsch T. Serotonin 5-HT1B/1D receptor, agonists areeffective in acute benign lymphocytic meningitis – a casereport. Cephalalgia. 2007;27:1174-1175.
7. Goadsby PJ. Serotonin receptors and the acute attack ofmigraine. Clin Neurosci. 1998;5:18-23.
8. Bartsch T, Knight YE, Goadsby PJ. Activation of5-HT1B/1D receptors in the periaqueductal grey inhibitsmeningeal nociception. Ann Neurol. 2004;56:371-381.
1236 September 2008
