Ketamine infusion therapy for refractory migraine
For chronic migraine that has not responded to standard treatment
The Restore Infusion
Ketamine infusion therapy for refractory migraine
This page is about ketamine infusion therapy for chronic migraine that has not responded to standard treatment. It is written more carefully than the rest of this site, and for a reason. The evidence for ketamine in migraine is real, but it is early, and it is thinner than the evidence in depression. You should know that before you call us rather than after you have booked a flight.
What migraine is, and what it is not
Migraine is not a bad headache. It is a neurological disorder, and in the United States it affects about 15.9 percent of adults, 21 percent of women and 10.7 percent of men [1]. It accounted for roughly four million emergency department visits in a single year, and headache was the third most common reason women aged 15 to 64 went to an emergency department at all [1].
People who live with it describe it in ways that someone who has never had one does not expect.
Like my brain is exploding, someone took a baseball bat and beat the base of my skull and neck with it, and there is an ice pick jabbed into my right eye and temple.
Like a vice around my head, with stabbing behind my ears and pressure behind my eyes. Pull the shades, lie down, do not move.
Mine begins when I lose peripheral vision and then become nauseous. My vision returns, only to have the pain start. It is an intense pain that makes you want to apply constant direct pressure to one part of your head to relieve it. It is painful even to open your eyes. I hate when people say, you have a headache. No, it is much more than that.
Those are descriptions of a neurological event. They are not descriptions of a headache.
Why some migraines stop responding to medication
Repeated attacks change the nervous system that carries and interprets pain. Pain pathways become easier to trigger and harder to switch off. Over time the threshold falls, attacks come more often, and medicines that once worked stop working. Pain specialists call this central sensitization.
Glutamate is the brain’s main excitatory signaling chemical, and it sits at the center of that process. Glutamate signaling, and the NMDA receptor in particular, has been implicated in migraine for many years. That is the reason a drug acting at that receptor is of interest at all [2].
Ketamine blocks the NMDA receptor. It does not block glutamate, and no infusion rewires a brain. What it can do is interrupt, for a period, the signaling that keeps a sensitized pain system running. That is a more modest claim than the one usually made for it, and it is the one the evidence supports.
What the evidence actually shows
We are going to set this out plainly, because it is the part most clinic websites leave out.
The most complete review of ketamine for migraine and other primary headache disorders identified five randomized controlled trials, 193 patients in total, and rated the quality of that evidence as very low, because of small samples, risk of bias, and outcomes measured differently from study to study. The results were mixed. Intranasal ketamine improved the severity of aura but not its duration in one trial. It did not outperform metoclopramide and diphenhydramine for headache severity in another. Subcutaneous ketamine did better than saline in one. Intravenous ketamine did worse than prochlorperazine and diphenhydramine in another. The authors concluded that further controlled studies are needed [3].
The largest clinical series treated 77 patients with chronic migraine or new daily persistent headache, all of whom had already failed aggressive outpatient and inpatient treatment. Average pain fell from 7.1 to 3.8 out of 10, and 71.4 percent met the definition of an acute responder. At follow-up, 27.3 percent of those responders still had the benefit [4]. A smaller series of six patients admitted for continuous infusion reported the same shape of result [5].
A real-world study of 169 patients using intranasal ketamine for refractory chronic migraine found that 49.1 percent called it very effective and 35.5 percent said their quality of life was much better, while 74 percent reported at least one adverse effect [6].
Reviews of the field place ketamine among the treatments considered for migraine that has failed everything else, not among established treatments [7].
What that adds up to. There is enough evidence to justify offering ketamine to someone whose migraine has not responded to standard treatment. There is not enough evidence to promise anyone a result, and we will not. A specific success rate for ketamine in migraine is not something the published literature supports, from us or from anyone else.
Find out whether you are a candidate
The RESTORE Infusion
How we would treat you
If we accept you, the treatment is the one set out on our home page. Three infusions on three consecutive days, completed in a single visit. The dose calculated to reach and hold a target concentration in your blood rather than multiplied out from your body weight. A physician in the room for every minute of every infusion, monitoring at the standard used for procedural sedation.
Migraine is not depression, and we do not treat it as though it were. The concentration we aim for and the length of the infusion are set for pain rather than for mood, and they come from pain medicine rather than from psychiatry.
What we measure
Before treatment we record how many headache days you have in a month, how severe they are, and what you are taking for them. We record the same things afterward, at set intervals.
That is how you find out whether this worked, rather than relying on an impression of how the last few weeks felt. It also means the decision to give you another infusion is made on the numbers.
If the numbers do not move, we will tell you, and we will not keep treating you.
What ketamine cannot do for migraine
Ketamine is approved by the Food and Drug Administration as an anesthetic. It is not approved for migraine, and using it for migraine is off-label [8]. Off-label prescribing is lawful and ordinary in medicine. You are still entitled to know that this is what is being offered.
It is not a cure. Where it helps, the benefit commonly fades and has to be renewed. In the largest published series, most of the people who responded had lost the benefit by follow-up [4].
Side effects are common rather than rare. In the real-world study above, three quarters of patients reported at least one [6].
Some people get no benefit at all, and we cannot tell in advance who they will be.
A headache that comes on suddenly, is severe, and is unlike any you have had before is a medical emergency. Go to an emergency department. Ketamine therapy is scheduled care and is not a substitute for emergency assessment.
Before we accept you
Whether you are a candidate is a clinical decision, not a booking. We read your headache history, the treatments you have already tried, your current medicines, and the relevant laboratory work before we take you on.
Some people we turn down. It may be that something else is causing your headaches and needs attention first. It may be that ketamine is unlikely to help the particular problem you have. We would rather tell you that on the telephone than after you have paid for a flight.
What patients say
We do not reproduce patient reviews on this site. Our patients post them publicly on Google, unedited and unselected by us, and you can read all of them, including any that are critical, at the link below.
References
Every clinical statement on this page is referenced below. Where a number appears in the text, it points to the source listed here.
Talk to us before you book anything
The RESTORE Infusion
We look forward to speaking with you!
Contact us today to determine if RESTORE is right for you. Just email or call for more information. We are here to help!
The RESTORE Infusion Program of ketamine therapy.
Our email: restore@ketamineinstitute.com.
Or call us at : 800-850-6979