Middle Meningeal Artery Lidocaine Infusion for Refractory Migraine: Angiographic Dose Response and 3-Month Outcomes

Several studies have demonstrated the amelioration of refractory migraines with middle meningeal artery (MMA) intra-arterial lidocaine infusion, but the durability beyond 1 month is not well studied, and the angiographic dose response of lidocaine infusion was not previously evaluated. We aimed to assess the efficacy of middle meningeal artery lidocaine infusion in the treatment of refractory migraines at a 3-month follow-up.

We quantified the response to intra-arterial lidocaine infusion (maximum dose of 150 mg) in patients with refractory migraine using the Migraine Disability Assessment (MIDAS) evaluated pre- and posttreatment. At 3 months, We determined the MIDAS score changes, the proportion of responders (≥50% MIDAS reduction), the proportion of patients with "no disability" (MIDAS Grade 1), and the cessation of opioid medication for headache management measured at the last known follow-up. An angiographic dose response was quantified.

Eight patients were included in our analysis (mean age of 49.1 ± 13.2 years; 87.5% were women). The cohort comprised equal numbers of unilateral and bilateral MMA lidocaine infusions (4 each), with doses titrated from 50 to 150 mg per procedure. At 3 months posttreatment, the mean MIDAS score improved from 86.3 ± 40.1 to 23.5 ± 26.8 (p = 0.001, paired t-test), and 62.5% of the patients showed 50% MIDAS score reduction. The disability pre-treatment was classified as "severe disability" in all patients, and 50% achieved "no disability" (MIDAS Grade 1) at 3 months posttreatment. No adverse events were reported in any of the procedures. At last known follow-up of a median period of 9.8 months [range 4-21 months], three out of the four patients who were on opioid medication pre-treatment discontinued their opioid medications following MMA lidocaine infusion.

Intra-arterial lidocaine infusion was associated with sustained improvement at 3 months posttreatment in 50% of patients with refractory migraines.