Document 6479448

Clinical Rounds
62
S K I N & A L L E RG Y N E W S • July 2006
Chronic Migraine Treatment Tied to Nickel Allergy
BY BRUCE JANCIN
Denver Bureau
C H I C A G O — Think “nickel allergy” in
patients who complain of new-onset or
worsening migraine following percutaneous closure of a patent foramen ovale
or atrial septal defect, Dr. Jonathan M. Tobis urged at the annual meeting of the Society for Cardiovascular Angiography and
Interventions.
The devices for percutaneous closure
of interatrial communications are typically made of nitinol, a nickel-titanium alloy. Hypersensitivity to nickel is present
in 15% of the general population, making it the most common of contact allergens, noted Dr. Tobis, professor of
medicine at the University of California,
Los Angeles.
Ironically, treatment of chronic migraine is an increasingly popular, albeit
off-label, application for perThe devices for
cutaneous clopercutaneous
sure of patent
foramen ovale
closure of
(PFO) and atriinteratrial
al septal defects
(ASD). Dr. Tocommunications
bis said that of
are typically
150 patients
made of nitinol, a who received
an Amplatzer
nickel-titanium
PFO or ASD
alloy.
closure device
at the university during 2001-2005, 41% reported chest
pain, palpitations, or new-onset or worsening migraine following the percutaneous procedure. Thirty-seven patients
who complained of an adverse event underwent nickel patch testing using the
thin-layer rapid use epicutaneous test; 10
(27%) proved positive.
Seven patients—or 5% of all those who
underwent percutaneous closure—complained afterward of new-onset or increased frequency and severity of migraine with or without aura. Their average
Migraine Disability Assessment scores
were 0 before and 41 after the procedure.
The complication occurred in 2% of patients with a PFO closure device and 12%
of those who got the significantly bigger
ASD closure device.
Six patients with new or worsening migraine were tested for nickel allergy. Four
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proved positive. A small series, granted,
but the two-thirds prevalence raises interesting hypotheses, Dr. Tobis said.
The migraines responded dramatically
to clopidogrel, which was routinely prescribed for 30-90 days postprocedurally
along with long-term aspirin.
Headaches developed within a week of
stopping clopidogrel. After 3-5 days of
persistent migraine, the patients were
restarted on 75 mg/day of clopidogrel. All
of them reported total or near-total
headache relief within a few hours after
the first dose. The antiplatelet agent was
stopped once again a month later in two
patients; both experienced return of migraine within 5 days, and both became
headache-free within a few hours of
restarting clopidogrel.
One hypothesis is that a localized inflammatory reaction to the closure device
occurs in patients with nickel allergy as
well as in some who aren’t hypersensitive
to the metal but are exposed to a large load
in the form of an ASD device. This reaction might send inflammatory mediators
into the left atrium and from there to the
cerebral circulation, inducing migraine.
Clopidogrel’s potent anti-inflammatory
effect would explain the rapid symptomatic improvement seen with the drug, he
speculated.
The good news, Dr. Tobis added, is
that the new-onset or worsening migraines resolved within 6 months for all
seven patients.
■
The development of young dermatologic researchers and educators is the gateway to enhanced
patient care. The Board of Trustees of the Dermatology Foundation proudly acknowledges members of
the Leaders Society and Annenberg Circle who contributed more than $2.8 million in 2005 to shape
the future of medical and surgical dermatology. Consider making your investment to secure dermatology’s
future today. Call 847/328-2256 to join your colleagues in leadership giving.
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Alexander A. Fondak, MD
Debra L. Chernosky, MD
Jerry Foote, MD
Brian D. Cheshire, MD
Diane S. Ford, MD
Stephen E. Chiarello, MD
Douglass W. Forsha, MD
Katarina G. Chiller, MD
Jayne S. Fortson, MD
Cynthia T. Chow, MD
Scott W. Fosko, MD
Linda C. Chung-Honet, MD
Theodore N. Fotopoulos, MD
Holly H. Clark, MD
R. John Fox, Jr., MD
Justin W. Clark, MD
E. William Frank, MD
Lani E. Clark, MD
Paul J. Frank, MD
Robert A. Clark, MD
David F. Frankel, MD
David J. Clemons, MD
Mary F. Fredenberg, MD
David J. Cohen, MD
Lorna J. Fredrikson, MD
Ivan S. Cohen, MD
Michael J. Freeman, MD
Jack B. Cohen, DO
William E. Freeman, MD
Kenneth A. Cohen, MD
Michael Fretzin, MD
Michael S. Cohen, MD
Bert C. Frichot III, MD
William P. Coleman III, MD
Richard G. Fried, MD, PhD
Daniel W. Collison, MD
Ilona J. Frieden, MD
Marcus A. Conant, MD
Robert J. Friedman, MD
Michael W. Condie, MD
Alvin E. Friedman-Kien, MD
Patrick J. Condry, MD
Tony S. Fu, MD
Suzanne M. Connolly, MD
Wayne H. Fujita, MD
James B. Connors, MD
Charles S. Fulk, MD
Lucius P. Cook, MD
Maxwell A. Fung, MD
David Cooksey, MD
Toni Funicella, MD
Gerald E. Cooley, MD
Loren S. Funt, MD
David Cooper, MD, PhD
Francesca J. Fusco, MD
Joseph P. Cooper
Michelle B. Futral, MD
Michael E. Cormier, MD
Jay N. Gade, MD, PhD
Lynn A. Cornelius, MD
Joseph E. Gadzia, MD
William F. Cosulich, MD
Kevin J. Gaffney, MD
William F. Cothern, DO
Sharon A. Galvin, MD
Jenny Cotton, MD, PhD
Jerome M. Garden, MD
Mary L. Courrege, MD
Michele E. Gasiorowski, MD
Gary F. Cox, MD
Anthony A. Gaspari, MD
Sue E. Cox, MD
Rami E. Geffner, MD
Peggy S. Crawford, MD
John K. Geisse, MD
E. Patrick Creehan, MD
Ellen C. Gendler, MD
David L. Crosby, MD
Marguerite A. Germain, MD
Christopher P. Crotty, MD
Brian J. Gerondale, MD
Eileen Crowley, MD, PhD
Roy G. Geronemus, MD
Donald R. D’Annunzio, MD
Larisa J. Geskin, MD
Mark V. Dahl, MD
Garry B. Gewirtzman, MD
F. William Danby, MD
Ruby Ghadially, MD
Chester Danehower, Jr., MD
Mahmoud A. Ghannoum, PhD
Michael J. Dannenberg, MD
John J. Ghidoni, MD
Joel H. Datloff, MD
Vincenzo Giannelli, MD
Ronald S. Davis, MD
Irma Gigli, MD
Steven A. Davis, MD
Stuart R. Gildenberg, MD
Thomas L. Davis, MD
Philip W. Giles, MD
Janice L. DaVolio, MD
Michael Girardi, MD
T. Wayne Day, MD
Hayes B. Gladstone, MD
Fernando R. DeCastro, MD
Lynn A. Benson Glesne, MD
James Q. Del Rosso, DO
Linda M. Globerman, MD
Marie-France Demierre, MD
Richard G. Glogau, MD
Jau-Shyong Deng, MD
Hugh M. Gloster, Jr., MD
Lawrence J. Desjarlais, MD
Ronald L. Godbold, MD
Luis A. Diaz, MD
Leonard H. Goldberg, MD
Daniel B. Dietzman, MD
Orin M. Goldblum, MD
Gary P. Dillon, MD
Jeffry A. Goldes, MD
James G. Dinulos, MD
Jonathan N. Goldfarb, MD
Allison K. Divers, MD
Peter M. Goldman, MD
Andrzej A. Dlugosz, MD
Ronald Goldner, MD
Glenn A. Dobecki, MD
Herbert Goldschmidt, MD
Elizabeth Dolan, MD
Norman Goldstein, MD
Helene C. Dombrowski, MD
Loren E. Golitz, MD
Peter Donelan, MD
Herbert S. Golomb, MD
Heidi B. Donnelly, MD
Herbert P. Goodheart, MD
Lisa M. Donofrio, MD
Ellen M. Gordon, MD
Michael A. Dorman, MD
Kenneth B. Gordon, MD
C. William Doubleday, MD
Scott L. Gottlieb, MD
Thomas F. Downham II, MD
2 0 0 5
A N N E N B E R G
Ira H. Gouterman, MD
Donald J. Grande, MD
Sergei A. Grando, MD, PhD, DSc.
Richard D. Granstein, MD
Kevin D. Cooper, MD
Leslie C. Gray, MD
SUSTAINING MEMBERS
Charles H. Greenbaum, MD
Thomas W. Cooper, MD
($5,000 annual contribution
Joseph H. Greenberg, MD
Gregory J. Cox, MD, P.C.
Richard S. Greene, MD
beyond $25,000 pledge)
Judith E. Crowell, MD
Lawrence J. Gregg, MD
Rex A. Amonette, MD
Ponciano D. Cruz, Jr., MD
James F. Gregory, MD
Thomas W. Andrews, MD
C. Ralph Daniel III, MD
Roy C. Grekin, MD
Robert B. Ash, MD
Steven K. Grekin, DO
William P. Davey, MD
Scott C. Grevey, MD
Susan V. Bershad, MD
Vincent A. DeLeo, MD
Darrell Griffin, MD
David R. Bickers, MD
Jerry E. Dickson, MD
Edmond I. Griffin, MD
Roger
I.
Ceilley,
MD
William Dorner, Jr., MD
Thomas D. Griffin, MD
Clay J. Cockerell, MD
Jeffrey S. Dover, MD
Pearl E. Grimes, MD
Ronald E. Grimwood, MD
Howard V. Dubin, MD
Gary A. Dyer, MD
Joan M. Griner, MD
Dan A. Dunaway, MD
Richard L. Edelson, MD
Douglas Grossman, MD, PhD
W. Christopher Duncan, MD
James O. Ertle, MD
Karyn L. Grossman, MD
Madeleine Duvic, MD
Michael
H.
Gold,
MD
James B. Grossweiner, MD
Peter G. Ehrnstrom, MD
Gary Grove, PhD
Gloria F. Graham, MD
Boni E. Elewski, MD
Melvin S. Gruber, MD
James H. Graham, MD
Bruce P. Guido, MD
Charles N. Ellis, MD
C.
William
Hanke,
MD
Joan Guitart, MD
Melvin L. Elson, MD
Harley A. Haynes, MD
Terry P. Hadley, MD
Ervin H. Epstein, Jr., MD
Rebat M. Halder, MD
Jean M. Holland, MD
John H. Epstein, MD
Ronald D. Hall, MD
Coleman Jacobson, MD
William L. Epstein, MD
Russell P. Hall III, MD
Waine C. Johnson, MD
Christiaan P. Hallman, MD
David D. Fadness
Robert E. Jordon, MD
Bill H. Halmi, MD
Wayne A. Fagan, MD
Alan J. Halperin, MD
Gerald G. Krueger, MD
Janet A. Fairley, MD
Tiffani K. Hamilton, MD
Warwick L. Morison, MD
Patricia Farris, MD
Iltefat H. Hamzavi, MD
Dennis E. Newton III, MD
Patrick R. Feehan, MD
S.L. Husain Hamzavi, MD
Thomas G. Olsen, MD
C. David Hansen, MD
Steven R. Feldman, MD, PhD
Christopher B. Harmon, MD
Phoebe Rich, MD
Kathy A. Fields, MD
Allan C. Harrington, MD
Neil S. Sadick, MD
Marian C. Finan, MD
Laurie H. Harrington, MD
Daniel M. Stewart, DO
Frederick S. Fish III, MD
Matthew Harris, MD
Bruce
U.
Wintroub,
MD
Richard E. Fitzpatrick, MD
Robert Hartman, MD
Aubrey C. Hartmann, MD
Helen Flamenbaum, MD
Mitchell Wortzman, PhD
Allen D. Harves, MD
David N. Flieger, MD
Ruey J. Yu, PhD, OMD
Mark H. Hassel, MD
Michael J. Franzblau, MD
Richard J. Havens
Irwin M. Freedberg, MD∞
Curtis W. Hawkins, MD
David M. Adelson, MD
Phillip Frost, MD
Christine M. Hayes, MD
Susan K. Ailor, MD
Paul G. Hazen, MD
J. Harvey Gardner, MD
Adelaide A. Hebert, MD
D. Edgar Allen, MD
Lisa A. Garner, MD
Edward R. Heilman, MD
Tina S. Alster, MD
Jacquelyn B. Garrett, MD
Beverly L. Held, MD
Jeffrey
S.
Altman,
MD
Maria C. Garzon, MD
Stephen E. Helms, MD
Lawrence L. Anderson, MD
Bryon L. Gaul, MD
Michael S. Henner, MD
Diane
R.
Baker,
MD
Paul Getz, MD
W. Dean Henrichs, MD
Richard S. Herdener, MD
Phillip B. Bandel, MD
Barbara A. Gilchrest, MD
Ann E. Hern, MD
Joel R. Barkoff, MD
Anita C. Gilliam, MD, PhD
James H. Herndon, Jr., MD
Matthew
D.
Barrows,
MD
Robert F. Godwin, MD
Christina A. Herrick, MD, PhD
Rodney S.W. Basler, MD
David J. Goldberg, MD
Ngo T. Hien, MD
Eugene A. Bauer, MD
Michael T. Goldfarb, MD
Ann C. Hill, MD
Deborah C. Hilton, MD
Paul W. Becker, MD
Harry M. Goldin, MD
Peter D. Hino, MD
Paul R. Bergstresser, MD
Mitchel P. Goldman, MD
Ranella J. Hirsch, MD
Alan
R.
Berlin,
DO
Lowell A. Goldsmith, MD
Julie A. Hodge, MD, MPH.
Karl
R.
Beutner,
MD,
PhD
Ernesto Gonzalez, MD
Catherine A. Hoffman, MD
Jag Bhawan, MD
Lillian R. Graf, MD
Mark D. Hoffman, MD
Victoria L. Holloway, MD
Kenneth B. Bielinski, MD
Robert D. Greenberg, MD
J. William Holtze, MD
Joseph B. Bikowski, MD
Alexander S. Gross, MD
Mark J. Holzberg, MD
John Q. Binhlam, MD
John C. Hall, MD
John A. Honch, MD
Jay
E.
Birnbaum,
PhD
George W. Hambrick, Jr., MD
Richard H. Hope, MD
David E. Biro, MD
John R. Hamill, Jr., MD
Janine O. Hopkins, MD
Kay Bishop, MD
Terrence T. Hopkins, MD
Jon M. Hanifin, MD
Maria K. Hordinsky, MD
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Thomas D. Horn, MD
Jean L. Bolognia, MD
Thomas D. Harris, MD
Sharon L. Horton, MD
Ronald R. Brancaccio, MD
N. Patrick Hennessey, MD
Stephen N. Horwitz, MD
Martin
Braun
III,
MD
Gavin S. Herbert
Jeffrey C. Houin, Jr., MD
Jonith Y. Breadon, MD
Nancy S. House, MD
James J. Herrmann, MD
Stephen D. Houston, MD
Robert A. Briggaman, MD
Warren R. Heymann, MD
F. Lester Howsden, MD
Robert T. Brodell, MD
Juliana Hicks, MD
Susan M. Howsden, MD
Clarence W. Brown, Jr., MD
Edmund R. Hobbs, MD
Charles I. Huddleston, MD
Forrest
C.
Brown,
MD
Nathan R. Howe, MD, PhD.
Larry D. Hudson, MD
Marc D. Brown, MD
Michael J. Huether, MD
Christopher J. Huerter, MD
James C. Huff, MD
Stuart M. Brown, MD
Stuart I. Jacobs, MD
Robert H. Huff, MD
Karen E. Burke, MD, PhD
Marie-Louise Johnson, MD, PhD
David M. Huntley, MD
Lawrence
L.
Bushkell,
MD
Richard A. Johnson, MD
Mary E. Hurley, MD
Jeffrey P. Callen, MD
Timothy M. Johnson, MD
David L. Hurt, MD
Valerie D. Callender, MD
William D. Ju, MD
Francis W. Iacobellis, MD
J. David Igelman, MD
Douglas Canfield
John B. Kalis, MD
Sidney Indgin, MD
Robert G. Carney, Jr., MD
Matthew R. Kelleher, MD
Rosemarie Ingleton, MD
Jennifer
C.
Cather,
MD
David N. Kingsley, MD
Tim Ioannides, MD
S. Wright Caughman, MD
Arnold W. Klein, MD
Brandith Irwin, MD
Marvin E. Chernosky, MD
Jeffrey A. Klein, MD
J. Mark Jackson, MD
Robert L. Jackson, MD
Neldagae S. Chisa, MD
Jay C. Klemme, MD
Carolyn I. Jacob, MD
Richard A. Clark, MD
Albert M. Kligman, MD, PhD
Gail T. Jacoby, MD
Stephen
W.
Clark
Thomas Kupper, MD
David F. Jaffe, MD
Mark
G.
Cleveland,
MD,
PhD
Marilyn S. Kwolek, MD
Michelle A. Jahnke, MD
Lisa M. Cohen, MD
Walter G. Larsen, MD
William D. James, MD
Steven R. Cohen, MD, MPH
Christine Jaworsky, MD
Thomas J. Lawley, MD
Kraig K. Jenson, MD
Brett M. Coldiron, MD
Ira Lawrence, MD
Joy D. Jester, MD
Timothy M. Jochen, MD
Richard S. Kalish, MD, PhD Timothy F. Kelly, MD
J. Matthew Knight, MD
Bernett L. Johnson, MD
Charles D. Kennard, MD
Hideko Kamino, MD
Ronald C. Knipe, MD
Beverly A. Johnson, MD
Julie R. Kenner, MD
Kay S. Kane, MD
Caroline S. Koblenzer, MD
Carl A. Johnson, MD
William
S.
Ketcham,
MD
Sewon Kang, MD
Robert V. Kolbusz, MD
Derek H. Jones, MD
Jeffrey S. Kezis, MD
Grace F. Kao, MD
Steven A. Kolenik III, MD
Robert E. Jones, MD
Suzanne L. Kilmer, MD
D. Scott Karempelis, MD
Hazle S. Konerding, MD
Robert M. Jones, MD
Timothy
M.
Kilpatrick,
MD
Scott
B.
Karlene,
MD
Robert A. Koppel, MD
Joseph L. Jorizzo, MD
Candance K. Kimbrough-Green, MD Neil J. Korman, MD, PhD
Candace S. Kasper, MD
Aaron K. Joseph, MD
Laura A. King, MD
Seth G. Kates, MD
Bruce W. Kornfeld, MD
Lawrence M. Joseph, MD
Lloyd E. King, Jr., MD, PhD
Robert Katz, MD
Stephen O. Kovacs, MD
Kastytis A.V. Jucas, MD
Robert S. Kirsner, MD
Donald M. Kay, MD
Alexander P. Kowalczyk, MD
Kathleen W. Judge, MD
Sidney N. Klaus, MD
James V. Kowalski, MD
Jacqueline M. Junkins-Hopkins, MD John D. Kayal, MD
Lester Klein, MD
Valda N. Kaye, MD
Nomate Kpea, DO
Ronald S. Jurzyk, MD
Marla
M.
Klein,
MD
Amelia H. Kaymen, MD
E. Michael Kramer, MD
Steven M. Kahn, MD
Gail A. Kleman, MD
John T. Keane, MD
James M. Krell, MD
Kays H. Kaidbey, MD
Mark A. Knautz, MD
Karen L. Keller, MD
Douglas W. Kress, MD
Lenore S. Kakita, MD
C
Geral
Phil L
Mark
Franc
Robe
David
Alber
Barry
Stuar
Steph
Gary
Henr
Mark
Peter
Mary
James
Micha
Eugen
Steph
Mary
Barba
Robe
Elizab
Robe
Robe
Robe
Jenni
Thom
Alan
Andr
Grego
Dona
Marti
D. Sc
Stanl
John
Ange
Eliot
Rona
Peter
M. Ga
Howa
Diya
Doug
Lee T
Marcy
David
Maria
Glenn
Peter
Marg
Richa
Geral
Lafay
Amy
David
John
Willia
Barry
Nicho
Sheld
Frank
R. To
Rhon
Rona
Desir
Maril
Barba
Kathl
Lisa J
Arthu
Julee
Mitch
Wend
Katie
Roy S
Alain
Robe
Jill R
Carl B
Louis
Earl J
Leslie
Willia
Richa
Jimm
Lincoln
Esta Kro
Paul A.
George
Emanue
Kevin B
Carol L.
Dennis
Joseph
THIS