Conference News Roundup—American Society of Anesthesiologists

Botox May Benefit Children With Hard-to-Treat Migraines

Injections of botulinum toxin (Botox) may provide significant relief for children with migraine headaches that do not respond to traditional treatment, suggests a small preliminary study.

Botox is approved by the FDA to treat migraines in adults. One in 10 school-aged children and teens have migraines, but there are few FDA-approved medications for this age group. Some children and teens do not respond well to available options, such as certain migraine rescue pain medications, and the pain and disability of migraines can have a severe impact on their lives. Preventative medications may help sometimes. Only one preventative migraine medication, topiramate, is approved for adolescents, however.

“When children and teens have migraine pain, it can severely affect their lives and ability to function. They miss school, their grades suffer, and they are left behind, often unable to reach their full potential. Clearly, there is a need for an alternative treatment for those who have not found relief,” said Shalini Shah, MD, lead author of the study and Chief of the Division of Pain Medicine at the University of California, Irvine. “After treatment, we saw improvement in functional aspects in all of the children and teens. In fact, one patient was hospitalized monthly for her migraine pain prior to Botox treatment and was expected to be held back in school. After treatment, she only has one or two migraines a year, and is excelling in college.”

The study included nine children and teens (ages 8 to 17) who had migraines on eight to 29.5 days per month. Most participants had tried numerous medications and other therapies without much relief. All received Botox injections in the front and back of the head and neck every 12 weeks and were evaluated during a five-year period. After treatment, the patients had migraines on two to 10 days per month.

In addition, when treated participants did have migraines, their headaches did not last as long. Patients’ migraines lasted from 30 minutes to 24 hours before treatment, and 15 minutes to seven hours after treatment. Their headaches also were not as painful. Patient-reported pain on a scale of 1–10 (from no pain to worst pain imaginable) ranged from 4 to 8 before treatment and 1.75 to 5 after treatment.

Eight adverse events were reported during the study. Most resulted from pain at the injection site. No severe adverse events were reported.

If the results of the current study are confirmed, Botox could provide an alternative for patients without treatment options, said Dr. Shah. Her team is enrolling patients to study this treatment in a prospective, randomized, double-blinded trial to compare Botox with placebo.

“Many current migraine medications have side effects, including sedation, dry mouth, and confusion, which are not well-tolerated in children and teens,” said Dr. Shah. “Our research of Botox is part of an effort to find better treatments for children and teens with migraines so they can realize their full potential.”

The study authors received no funding from the manufacturer of Botox.

Diabetes Increases Risk of Cognitive Problems After Surgery

Older patients with diabetes may be at an 84% higher risk of developing postoperative cognitive dysfunction (POCD) than those who are not diabetic, new research suggests.

“With POCD, a patient’s mental ability declines after surgery, compared to their cognitive performance before surgery, resulting not only in increased complications and potential death, but also impairing the patient’s quality of life,” said Gunnar Lachmann, MD, Department of Anesthesiology and Operative Intensive Care Medicine, Charité—Universitätsmedizin Berlin. “POCD is increasingly recognized as a common complication after major surgery, affecting 10% to 13% of patients, with seniors being especially vulnerable.”

POCD is a major form of cognitive disturbance that can occur after anesthesia and surgery, but little is known about its potential risk factors. An association between diabetes and age-related cognitive impairment is well established, but the role diabetes has in the development of POCD is unknown.

In the study, researchers performed a secondary analysis of three studies, comprising 1,034 patients (481 who had cardiac surgery and 553 who had noncardiac surgery), to examine whether diabetes was a risk factor for POCD. Patients’ mean age was 66.4. Of the 1,034 participants, 18.6% had diabetes. The association of diabetes with risk of POCD was determined using logistic regression models at the longest patient follow-up period for each study, which was three or 12 months. Risk estimates were pooled across all three studies.

After adjusting for age, sex, surgery type, randomization, obesity, and hypertension, the researchers determined that diabetes was associated with an 84% higher risk of POCD. Patients age 65 or older were at particularly high risk.

“Our findings suggest that consideration of diabetes status may be helpful for the assessment of POCD risk among patients undergoing surgery,” said Dr. Lachmann. “Further studies are warranted to examine the potential mechanisms of this association, to ultimately help in the development of potential strategies for prevention.”

In 2015, the American Society of Anesthesiologists launched a patient safety initiative—the Brain Health Initiative—to provide physician anesthesiologists and other clinicians involved in perioperative care, as well as patients and their families caring for older surgical patients, with the tools and resources necessary to optimize the cognitive recovery and perioperative experience for adults age 65 and older undergoing surgery.