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 SMART PHYSICIANS SMART CHOICES gy News Skin & Aller C OSM ECE UTI CAL C RIT IQU E: S UNF LOW ER O IL , PAG E 23 matol .com tic Der lergy news al, and Aesthe Surgic .skin andal Medic al, er for T he Leadin pende g Inde www nt Ne wspap DE INSI O. 6 36, N JUNE ogy P RO & C ON : A RE M OHS F ELLO WSH Skin & Allergy 2005 ne Restyla Foreign Linked to Batches Reactions price. Allergic VO L . 3 6 , N O. 5 T he Leadin g s lured Physician on alterati lergic reactio a critical Klein, “That was t,” said Dr. Klein produc Arnold W. in the the the Unis. ology at who holds st Bureau in dermat nia, Los Angelein Southwe When Acne - chair Califor completed — Dermaof versity of ation trial, Attackstreatment RIZ. 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In early your by nted that ry indicated that health advisopagemen anesthe said has taken “We really are tal What’s Month for 31676 the ,” the topical cineurin spite the patients of the urinary frequenc to the hospithis action, ability of topical inhibitor fact that tinence. safety to their efficacyof VanSee Case of all ages and to see form there [are] de- only as directed s should be calIn late 2003, y and inconboth to perused ers, B.M., a scalp no relation he develope and dermato medical and surgical rash. AD Carruth logy. 32517 d nosed. A See Challeng only after Alastair B.C. was again “It allows a balance clobetasol ed page diagpoo regimen couver, 16 to have ever and tar spectrum you to do the shamyielded whole “We have can just go onof medicin ment. In hoto.a no improve organ system,” e within 2004, he You more rapid one presente here. had ear said31447.p Jean Bolognia d with r and ever pain ease stronge What’s your a painful rash. and , 31447.t diagnosi the Month s? See Case page 71 unds Compo Topical ted in Deaths Implica C OURTESY VO L . of 32544 hoto Section Color: Screens: Informat ion: 31933 31933.p hoto See Case of the Month page 31255.tea 71 31255.ph se.sa oto.a 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. 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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 Marshall L. Blankenship, MD John M. Haraldsen, MD 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. 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