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.