2. CASE REPORT
History of presenting condition
A 47-year-old woman presented with a history of headache and neck pain
for the past 35 years. She had not consulted a specialist for the
treatment of headache and had been taking OTC analgesics almost daily.
Her headache, which was described as bilateral, non-pulsatile, and dull,
persisted despite using OTC analgesics. In July 2016, the patient
developed diplopia, with diurnal fluctuation and limb fatigue. On
reviewing at the Department of Neurology, the patient was diagnosed with
generalized MG (class IIa) based on positive results for
anti-acetylcholine receptor antibodies and without thymoma. In
September, prednisolone and immunosuppressants were administered. She
sought consultation for her headache during the visit. The attending
physician considered MOH and thus, prescribed muscle relaxants instead
of analgesics to manage the headache. However, the patient continued
using OTC medication despite understanding the analgesic restriction and
failed to disclose to the attending physician about using OTC
medications. In November, she was hospitalized owing to worsening of MG.
The fatigue symptoms disappeared with immunoadsorption plasmapheresis,
and intravenous immunoglobulin (IVIg) administration (400 mg/kg × 5
days). She had severe headaches while receiving IVIg. During the second
admission in September 2017, the severe headaches recurred on the
3rd day of IVIg therapy. Based on The International
Classification of Headache Disorders, 3rd edition,
aseptic (non-infectious) meningitis was excluded as a cause of the
headache. During hospitalization, she was referred to our department for
management of tension-type headache.
Description of patient
At the first visit to our department, she had a pulsatile global
headache associated with nausea and vomiting. This headache was
different from her usual headaches. We confirmed her history of
long-term analgesic use for her usual headaches. MG symptoms included
diplopia and limb muscle weakness with diurnal variation (Osserman
classification: II B). Physical examination revealed remarkable
tenderness and increased muscle tone of the cervical shoulder muscle
group and neck pain induced by neck movement. Deep tendon reflexes and
tactile sensation were intact. A manual muscle test showed weakness of
the upper and lower limbs.
The medications being used were prednisolone 10 mg/day, cyclosporine 150
mg/day, ambenonium chloride 5 mg/day, alendronic acid 35 mg/weekly, and
tizanidine 3 mg/day. Loxoprofen 60 mg was used as a single dose.
Acupuncture treatment
Acupuncture treatment was carried out by a licensed acupuncturist with 5
years of clinical experience. The frequency of acupuncture for treatment
was once a week from the first visit to the 4th visit,
twice a month from the 5th to 8thvisit, and once a month after the 9th visit.
Acupuncture was performed using stainless steel disposable acupuncture
needles (length: 40 mm, diameter: 0.16 mm, Seirin Co., Ltd.). Acupoints
were selected based on our previous studies.4 The
purpose of acupuncture was to relieve pain and tone in the neck muscle
and to normalize the central sensitization. The acupoints used were GB20
on the plate muscle; BL10 and GB21 on the trapezius muscle; SI14 on the
levator scapula muscle; BL43 on the rhomboid muscle; and GB5, BL2, ST6,
and ST7 in the trigeminal nerve area. After insertion, the needle was
left in place for 10 min. Press-tuck needle (diameter: 0.9 mm, Seirin
Co., Ltd.) was applied to the trapezius, plate and elevator scapulae
muscles, which had remarkable muscle tone. A headache diary was used to
evaluate the frequency and duration of the headache and the number of
times loxoprofen was taken.
Outcomes and follow-up
Historical and current information from this episode of care organized
as a timeline was shown in Figure 1. The headache diary was used to
evaluate the frequency and duration of headache and the number of taking
loxoprofen. Acupuncture treatment for about a year reduced the days with
headache and consumption of loxoprofen (Figure 2). Initial days with
headache and number of taking loxoprofen were 18 and 7 days. Both
decreased gradually, and one year later, the days with headache were
reduced to 7 days, and number of taking loxoprofen was reduced to 3
days, respectively. Furthermore, the acupuncturist heard about the
patient’s use of OTC analgesic, and explained about MOH during medical
interviews and treatments. The acupuncturist advised her to follow her
attending physician’s instructions regarding medication, and she
succeeded in stopping the use of OTC analgesics.