Acupuncture and auricular cryotherapy for chronic headache in a patient with type III von Willebrand disease.

A 42-year-old women was referred to our pain therapy centre in April 2013 owing to a worsening migraine. She was known to have von Willebrand disease type III complicated by the development of alloantibodies to von Willebrand factor and previous anaphylactic shock during infusion of factor VIII/ von Willebrand factor concentrates. The patient is being treated with a continuous infusion of recombinant factor VIII, when bleeding occurs. Since the age of 14, the patient has received combination oestrogen and progestogen treatment to prevent the risk of bleeding related to ovulation. She has no other relevant medical history. Migraine pain began at the start of 2007, and rapidly became severe (typically scoring 8–10 on the numerical rating scale (NRS) for a period of 72 h). The pain was treated with paracetamol, sumatriptan and rizatriptan in turn, without success. In view of her lifelong bleeding tendency, the use of nonsteroidal anti-inflammatory drugs was avoided. Prophylactic therapy was started with propranolol and then with flunarizine, without benefit. The pain pattern was typical of migraine and started from the 21st day of her menstrual cycle and stopped at the 28th day, when combined oestrogen and progestogen therapy was restarted. In the past 3 years, the migraine pain has been reaching an NRS of 10, lasting for 7 days, and moreover, not limited just to the period of suspension of oestrogen and progestogen therapy. The patient has had more than three migraines each month, and thus has had pain for 10–15 days every month with an NRS of between 8 and 10 and little relief from the available treatment (triptans). Five to six episodes/year have required hospital attendance, admission and treatment with IV ketorolac and mannitol. CT and MR scans have been performed five times in the past 3 years and were always negative. After the initial consultation, the patient was asked to register pain intensity, duration and drug consumption in a diary for 6 weeks before the beginning of acupuncture therapy; amitriptyline 10 mg/ day was given and rizatriptan 5 mg was the rescue treatment. No change in hormone therapy was made because the risk of intraperitoneal bleeding during ovulation was considered too high.