For years, Hayley Striegel has suffered from persistent, disabling, treatment-resistant migraines, also known as refractory migraines. She tried countless treatments over the years but nothing provided significant relief, until she was referred to Dr. David Fiorella at Stony Brook Medicine.
In this episode of Healthcast, Hayley and Dr. Fiorella discuss a new targeted lidocaine infusion therapy that Hayley has experienced great relief with.
The Experts
- David Fiorella, MD, PhD
- Patient: Hayley Striegel
That You’ll Hear in This Episode
- 00:00: Opening and Introductions
- 2:36: Refractory Migraines
- 4:21 Hayley’s Journey with Refractory Migraines
- 7:56: Middle Meningeal Artery & Headaches
- 9:00: Lidocaine Infusions for Headache & Migraine Relief
- 10:45: Lidocaine Infusion Process and Results
- 13:28: Hayley’s Experience with Lidocaine Infusion
- 14:23: Migraines vs. Refractory Migraines
- 15:40: Dr. Fiorella’s New Study
- 16:40: Lidocaine Infusion Catheterization Procedure
- 21:22: Impact of Hayley’s Medical Journey on Her Future Plans
- 23:42: Future of Migraine Medicine
- 24:44: Hayley’s Personal & Professional Future
- 26:06: Closing Remarks
Full Transcript
00:00: Opening and Introductions
Announcer
Welcome to Healthcast, where leaders and experts from Stony Brook Medicine come together to discuss a range of topics from leadership and strategic planning to patient care and the inner workings of a successful health care system.
Timothy Brown
Welcome to Healthcast, where we dive into groundbreaking medical advancements, inspiring patient stories, and the latest in health and wellness. Now, today, we’re going to have another great episode for you – one that could change the way we think about treatment resistant migraines.
Joining us today is Dr. David Fiorella, a true pioneer in neurointerventional therapies and procedures here at Stony Brook Medicine.
And alongside him, we have Hayley Striegel, a fourth year medical student in neighboring Nassau County. Now, for years, Hayley has suffered from persistent, disabling treatment-resistant migraines, also known as refractory migraines. She had tried dozens of treatments, even requiring hospitalization in an attempt to stop the pain, but nothing provided significant relief. That is, until she was referred to Dr. Fiorella.
After meeting with Dr. Fiorella, Hayley agreed to try a new targeted lidocaine infusion therapy. And while today’s episode is focused on treatment resistant migraines, it is worth mentioning that Dr. Fiorella has also pioneered another groundbreaking treatment targeting the middle meningeal artery for a different chronic condition involving headaches. In fact, his work was recently published in the prestigious New England Journal of Medicine. So we’re definitely speaking with an expert in the field today.
So Dr. Firella and Hayley, first of all, welcome to the program. Thank you very much for being on. And if I can just have you introduce yourselves to our audience and tell us a little bit about yourselves. Hayley, let’s start with you since you drew the short straw and you’re closest to me.
Hayley Striegel
Okay, sounds good. My name is Hayley Striegel and I’ve been a patient of Dr. Fiorella since September of 2023.
I am a fourth year medical student at the Zucker School of Medicine at Hofstra, Northwell, on Long Island. And I’m actually applying to neurology residency right now to become a headache specialist. I have had status migrainosus for almost three years now – a type of refractory migraine.
David Fiorella, MD, PhD
I’m Dave Fiorella. I’m the head of the Cerebrovascular Center here at Stony Brook Medicine in the Department of Neurosurgery. And basically, I do all the catheter based procedures, interventions for anything that has to do with the brain, head, neck or spine here at Stony Brook. I’ve been here for over 15 years now.
2:36: Refractory Migraines
Timothy Brown
Great. So Dr. Fiorella, I’m going to start off with you, and we will get into Hayley’s story here in just a moment. But first of all, talk to us about refractory migraines.
What is that? What does that mean?
David Fiorella, MD, PhD
Refractory migraine is a condition where our patients have migraine headaches that are poorly managed by all the available therapies that we have today. So these patients are typically on maintenance medications as well as breakthrough medications.
And really, there’s been so much that’s been done recently with headache therapies and migraine therapies. You see from all the TV commercials that we have every single day about all the various medications that are available for these things.
But interestingly, anywhere between two and 12 million people in the United States are affected by this condition called chronic refractory migraine, where despite all of these medications, these patients are experiencing multiple headache days a month, meaning they’re disabled by their headaches multiple times per month. And that’s despite all of these other medications that they’re taking.
And so this approach that we’re describing today is something that potentially is useful for patients just like that. So patients who are on all the maintenance medications, who are taking many breakthrough medications, but still are experiencing multiple days per month where they’re unable to work or unable to function because of these types of migraine headaches.
For any of you who have had a migraine headache, and I’ve only had a handful in my life and was completely disabled for those days when I’ve had some. And so if you have people, almost everybody knows somebody in their own life from their personal life or sometimes personally themselves who suffer from this, that’s how common it is.
The idea that some people could be on all these different medications and still be suffering from this multiple days a month is just unbelievable to me. I don’t know how I would function or how I could do my job if I was facing that. And, you know, meeting somebody like Hayleyreally brought it home – to what this means to somebody in the medical profession.
4:21 Hayley’s Journey with Refractory Migraines
Timothy Brown
Well, Hayley, first of all, I was just going to say how impressed I am with you because not only do you suffer from this situation, but you’re a med student, which is not an easy thing in of itself, and you’re managing.
Tell us what it’s like to suffer through these refractory migraines. What’s the situation like for you?
Hayley Striegel
I used to have episodic migraine, which is a migraine where you have migraine frequently. For me it was quite frequent, around 13 days a month, and that was quite bothersome. But I really just fell into despair when I started to experience status migrainosus. In my case, it’s been a continuous migraine lasting nearly three years now.
It’s just an unimaginable sort of pain that couldn’t even compare to the already immense pain that I was experiencing with episodic migraine. It was just, you know, you want to be able to live your life and do all of the things that comes with that, like medical school or just spending time with friends and family and fulfilling obligations.
It was just an immense burden because it felt like I just wasn’t myself. I was somebody who was grouchy all of the time and, you know, just uncomfortable all of the time. And it’s impossible to imagine until you experience it, I think.
Timothy Brown
Yeah, I can’t even imagine. And I wouldn’t blame you for being grouchy if you’re in constant pain. I mean, that’s got to be very difficult.
Tell us how you came to Dr. Fiorella because you were actually going through another treatment prior to that, right?
Hayley Striegel
Yeah. So actually, I had tried many dozens of migraine treatments once I started to experience status migrainosus and before that. And due to side effects or whatever it might be, I was unable to tolerate them.
Eventually, a therapy for some people experiencing prolonged migraine is to be hospitalized. And I was hospitalized and I received intravenous lidocaine and DHE, and at the end of my six days in the hospital my pain was unchanged and I was sent home. And basically the concept was like, there’s nothing left to do for you.
Timothy Brown
That’s not going to be devastating, at that point.
Hayley Striegel
It was. I was so saddened. I don’t know that there is a way to describe how I felt then, but yeah, that was probably my lowest point I can think of. And I had seen my neurologist and his medical assistant actually suggested that I see Dr. Fiorella. And I thought, well, it’s worth a shot. I’ll, you know, try one last thing and we’ll see what happens.
And it ended up being really amazing for me. I was so grateful to have had that kind of chance thought in the medical assistant’s mind that I should go see Dr. Fiorella.
7:56: Middle Meningeal Artery & Headaches
Timothy Brown
That’s fantastic. And I’m glad that worked out that way. Dr. Fiorella, can you tell us a little bit about the therapy that Hayley specifically received? And first of all, how did that come about and why would Hayley be a good candidate?
David Fiorella, MD, PhD
Well, for a long time, about five or six years ago, we had innovated a procedure here called embolization of the middle meningeal artery for patients with subdural hematoma. So one of the chronic symptoms that these patients have with chronic subdural hematoma is headache, very similar to the patients experiencing migraines.
And one of the things we saw that was really interesting is we treated patients by embolizing their middle meningeal arteries and before their subdurals would better at all, they would have headache resolution almost immediately afterwards. And we didn’t really understand why that was and that was interesting to me.
9:00: Lidocaine Infusions for Headache & Migraine Relief
So I started looking into the literature about who else had investigated the middle meningeal artery and its potential links to headaches, and there’s a huge literature about whether dilation or pathologic constriction of the arteries related to headaches. And then I came across a couple of papers by a man named Adnan Qureshi, who interestingly was an interventionist at the Cleveland Clinic when I was at the Cleveland Clinic. And he had just had a small series of cases, six patients, where they had refractory headaches related to a previous intracranial hemorrhage, like a brain hemorrhage or a subarachnoid hemorrhage or something like this.
And he had done infusions of lidocaine and noticed that even though the lidocaine half life is about an hour and a half, when he did these lidocaine infusions they relieve these headaches and sometimes the relief was fairly prolonged, sometimes a couple of weeks. And so I came to this idea that perhaps if we did these lidocaine infusions into the bilateral middle meningeal arteries of potentially patients who had migraine headaches without any other predisposing cause could potentially respond to this.
In investigating the use of lidocaine for headaches, I came across these articles from Thomas Jefferson University, which is where I believe Hayley went. And what they started doing is an innovative technique where they actually admit patients to a unit and they put an I.V. and administer them gigantic doses of lidocaine over a period of a week. So these are patients who are, you know, generally high functioning patients from all over the country and are so desperate from their migraines, they’re traveling to Philadelphia to be admitted in an inpatient unit and undergo days of prolonged lidocaine infusions.
So they’re monitoring you, checking your levels, and then just hoping that they break their headaches. And if they do break their headaches, they do have success in a lot of these patients. Typically it lasts for a couple of weeks and then either they have to undergo the infusions again or they’re back to their baseline.
10:45: Lidocaine Infusion Process and Results
And so this is interesting to me. There was a middle meningeal artery idea. There was the idea that there were a few cases of this, and then the idea that you would flood the whole system with lidocaine and perhaps that helped. And so we got the idea that if we were able to infuse the lidocaine selectively into the middle meningeal artery and just get to the meninges, that perhaps we’d get a much higher effective dose of this medication to the area where it needed to go and perhaps this was going to be the answer.
And so what we started to do is in patients like Hayley, these are patients who were just completely at the end of the rope. They’ve been treated with all the baseline breakthrough medications and maintenance medications, and they’re still having all these headache days a month. So we were asking the neurologists, you know, send us the worst of the worst patients who are just so desperate because we have something and perhaps it will help.
And it’s something that’s extraordinarily safe and easy to do. It’s a radial artery access puncture with a small gauge catheter. And then we just guide the catheters up under minimal x-ray exposure.
The idea is that if we administer it locally, we’re getting like a thousand times higher concentration than if we’re administering it peripherally.
And so the idea is to get the medication to where it needs to go in the highest possible dose, getting a very local effect of the lidocaine. And the whole infusion process takes from beginning to end will take about a half an hour rather than being in the hospital for a week. You get an outpatient procedure for a half an hour and by lunchtime, you’re out of the hospital, hopefully having lunch and going about your normal day.
And so that was the idea. And we started doing it in patients like Hayley, who had exhausted all of their other options and were desperate for anything that might help. And we were surprised to see that in a substantial number of the patients, it did give them help and that help was fairly durable. And while we don’t have really high level evidence to support this right now, it’s a really new therapy, we have had success in many, many patients like Hayley, who really have exhausted a lot of their other options.
And so we couldn’t be more excited about this. And what this has to offer patients. The idea is that this doesn’t replace any of their ongoing therapies. So if they’re getting Botox injections, we encourage them to keep doing that. Stay on all of your maintenance medications and you still have your breakthrough medications when you need them.
This is purely an adjunctive procedure that doesn’t get rid of all their headaches. The idea is it makes all their medications work a little bit better or sometimes a lot better. And so we’ve had patients who on the table are getting headache relief while the infusions are going in. And it’s so gratifying when you have one of those patients, because we’ll see the patients – sometimes they’re getting tearful on the table. And I wonder, you know, are you okay? Are you doing okay? And what they’ll say to me, it’s always the same thing every time they’ll say, like, “You know, Dave, I just don’t remember when the last time was that I didn’t have a headache. Like, I don’t remember what it’s like to feel like that.”
So it would be a very emotional experience for the patients and the idea that it lasts so much longer than the infusion is something that’s curious to us, but something that’s really interesting and it’s been now reproduced in multiple other areas. And so we started doing these cases and one of my colleagues from Memphis, Dr. Adam Arthur, we talked about this. Now he started doing these cases.
Now we have over 40 patients where we’ve done these infusions. And so we’re starting to get some real data in terms of how frequently it works and how long it lasts.
13:28: Hayley’s Experience with Lidocaine Infusion
Timothy Brown
That’s fantastic. Hayley, tell us about your experience when you actually got the infusion. Was it almost immediate like that, or what did it feel like?
Hayley Striegel
I honestly can’t remember. It’s been like a year and a half now, I think, since the first one. All I know is that in the week or so, the days or week following the infusion, I really felt like, wow, I have not had any stretch of time where I was just not so burdened by my pain all of the time, where I could go minutes or hours without thinking about the fact that I had a migraine.
And I think that spoke to the decrease in the pain that I was experiencing. It was really profound for me. I think my mental health improved right away because I was just so mentally burdened by the pain that I was experiencing all of the time.
14:23: Migraines vs. Refractory Migraines
Timothy Brown
It’s incredible. So, Dave, for migraines in general, women suffer migraines more often. Is it the same for refractory migraines?
David Fiorella, MD, PhD
Yeah, it seems like that. It seems like it’s more female than male patients, although certainly we’ve treated both males and females with the therapy.
Timothy Brown
Do we know why?
David Fiorella, MD, PhD
I don’t think we do. I think there may be some hormonal link to it. It seems to fluctuate sometimes with puberty in adolescence and get worse sort of around the late teens and that period of time. But I don’t know that we have great data in terms of why that’s the case.
Timothy Brown
Hayley, talk about your situation a little bit. When you suffer from one of these migraines, how does it come on and what do you go through when that happens to you?
Hayley Striegel
I think refractory migraine is not different, typically, than a non refractory migraine. I think that the difference really is that patients have been trying preventative therapies that are not working. And if we’re using strict definitions, they’ve exhausted all the classes of preventatives without finding something that was either not contraindicated or that worked.
15:40: Dr. Fiorella’s New Study
Timothy Brown
Okay. So Dave, you mentioned your study that you’re working on right now, and it was recently published, is that correct?
David Fiorella, MD, PhD
Yeah, we just submitted our initial 45 patients for a publication that was accepted to the Journal of Neurointerventional Surgery. And so we learned a lot from that case series. In these patients, they were all referred from a neurology practice. All of them had exhausted all the available medications, and so we took those patients, the worst of the worst, and about 60 percent of them had a significant response or improvement to their condition.
So an improvement is greater than a 50 percent reduction in their number of headache days per month. So it’s not again, curing headaches in all patients. All we’re trying to do is make them better so that they’re having fewer headache days a month, significantly fewer, less than half of what they were having at baseline was what was defined as success.
So if patients responded on the table, about 85 percent of those that responded on the table had durable relief that lasted approximately four weeks or more in some cases. Some patients had relief out to two and three months from one infusion.
16:40: Lidocaine Infusion Catheterization Procedure
Timothy Brown
So the actual process, you mentioned the catheter. So are you looking at the specific area that you want to target? And I’m assuming you do that through a variety of different ways. But how does that work?
David Fiorella, MD, PhD
Yeah. So it’s really like almost any kind of catheterization procedure. You hear people get a heart catheterization for heart blockages – we do similar catheterizations to look at the arteries of the neck and the head and do diagnostic angiography. And really this is just a small extension from a normal diagnostic angiogram.
Basically, for the specific lidocaine infusion procedure, we give patients a little bit of medication through the intravenous just to get them relaxed. At the beginning of the procedure, we numb up an area over the radial artery, which is just over the wrist, and then place a small IV tube into that. And then under direct X-ray guidance, I’m watching my catheters.
I manipulate them over a small micro wire under X-ray guidance and then manipulate those catheters in what’s called the external carotid artery. The external carotid artery feeds the arteries of the face and and the soft tissues over the face and scalp, but also supply the middle meningeal artery that supplies the coverings of the brain, the dura, which is one of the most pain sensitive areas of the entire brain.
And so we guide a small micro catheter through our diagnostic catheter into the middle meningeal artery, specifically. We do a small injection of contrast to verify that we’re in the right position, and then we just hook that up to an infuser and infuse 50 milligrams of lidocaine over about 7 to 10 minutes. And you could actually talk to the patient the entire time.
The patients are fully awake for this procedure. It’s relatively painless. When we do the lidocaine, sometimes you feel a little bit of that, sometimes if the catheter is going up, especially in these young women who have smaller arteries, they can actually feel the catheter in their artery a little bit. But by and large, Hayley can speak to how difficult it is to get through because she’s been through several.
Compared to the headache pain that these patients are experiencing, this is absolutely nothing. We do the infusions. And like I said, a lot of times patients will get relief right during the infusion. So we’ll do the left side and then usually we switch over, we’ll do the right side. We try to do both sides during the injection.
The whole procedure takes about 30 minutes from beginning to end. After the procedure, we just take the catheters out and put a little compression band over the wrist and then usually within an hour or two that compression band is off. Most of these patients are young, healthy women, so they have beautiful blood vessels to catheterize compared to a lot of the patients we have that are older patients, a lot of carotid disease and things like that.
So it’s a very safe and easy procedure. And now that we’ve done so many of these, we’ve gotten really streamlined with it to where we’re really limiting the number of pictures that we take, the amount of injections of contrast that we’re doing. And so we’re doing these procedures with really minimal radiation exposure and really minimal contrast dye burden.
And so it’s really one of the most minimally invasive procedures that we do. And because we’re working the arteries that go to the face and the coverings of the brain rather than the brain themselves, it’s extraordinarily safe. And so we’re not in the arteries that supply the actual brain. So the risk of anything happening from this like stroke or anything serious is really very minimal.
Today we’ve had no significant complications in any of the patients who’ve been treated and really substantial results so far, so it’s something that we’re really, really excited about.
Timothy Brown
Yeah, I mean, it sounds tremendous, fast, safe, minimally invasive. Hayley, from your experience, tell us a little bit about that. Is it pretty quick and painless?
Hayley Striegel
I would say so. I think the key is that there is anesthesia, and so that certainly helps. And, you know, the team is very responsive if I’m experiencing pain. And so I find something acutely painful like this to be relatively not bothersome for me. I think it’s chronic pain that is the most bothersome for me overall. So I certainly don’t mind something like this. Even if it were painful, I think I would take a small moment of pain to be unburdened by my pain the rest of the time.
Timothy Brown
How many have you had, how many infusions?
Hayley Striegel
I’m not sure of the exact number, but I think it’s somewhere between eight and ten would be my best guess.
Timothy Brown
And generally, how long does it last for you?
Hayley Striegel
I would say around 4 to 6 weeks.
Timothy Brown
Wow. Okay. That’s significant then.
Hayley Striegel
Yeah, it’s been really amazing. I think I just couldn’t have imagined that something like this existed. And I feel like I got lucky by having the problem that I had when I did, rather than maybe like five years ago when Stony Brook was not doing this.
21:22: Impact of Hayley’s Medical Journey on Her Future Plans
Timothy Brown
Well, I’ve got to say this again, I’m really impressed with you because for you to be going through what you were going through and also being a medical student, that cannot be easy. And this actually now has influenced your thinking as far as what you may want to do eventually. Tell us a little bit about that.
Hayley Striegel
Yeah, I’d like to be a headache specialist. I really found that when I first started to have status migrainosus, I would study and then I would get a thought in my head – a question about migraine or primary headache disorders or something like that. And I would go and I would look it up, and I spent maybe like half of the study time that I should have maybe been studying, just looking up various questions that I had about headache disorders.
And I realized that I think I should do this for my future specialty. I really fell in love with it and I just love the patients as well. It’s so gratifying, the idea that you can reduce someone’s pain by that much. And so that’s my goal. Speaking as to going through medical school with this amount of pain, I did have a lot of encouragement from a lot of angles, including when I was hospitalized to take leaves of absence or even drop out of school and I ended up deciding not to do that.
I took it seriously, the suggestion, but I realized that it was actually the purpose and the ultimate goal that brought me something to do, something joyful and happy in life and productive. It was meaningful as opposed to just kind of letting myself suffer all day. But of course, that’s not to discount the pain of people who truly are unable to go through with everyday life. You know, I certainly recognize that their pain and suffering is real.
23:42: Future of Migraine Medicine
Timothy Brown
Yeah, without a doubt. And what a fantastic outlook that you have and just the ability to take this and maybe make something positive out of it, I think is to be commended. I mean, I’m just really impressed. So that’s pretty awesome.
Tell us about the future. And Doctor, I want to start with you on this. What do you think? What do you see for the future in this area? It sounds like it’s an exciting time.
David Fiorella, MD, PhD
Yeah, it really is. So currently we’re just doing this as part of clinical practice so patients can seek out the therapy themselves or their neurologist can refer them for a consultation to see if they’re good candidates for this procedure.
And again, we’re looking for patients who have been on all of the maintenance medications and breakthrough medications and are still experiencing a significant number of migraine days per month. And I think it’s worth a try for patients like that.
But ultimately, really the most important thing is to do a prospective randomized controlled trial of this. And so we’re currently seeking various funding mechanisms and applying to do that to study this further.
And so we have some stuff off in the future and some stuff that we’re working on currently. We’re hoping to advance the science of the field. But in the meantime, the procedure is very safe. We’ve had good results and so we’re happy to offer it as part of routine clinical care as well.
24:44: Hayley’s Personal & Professional Future
Timothy Brown
Great. And Hayley, the future for you personally and also professionally, what do you see?
Hayley Striegel
I mean, I’m really excited to be able to try to match what I’ve achieved as a patient as a physician. And I really hope that this kind of therapy will be offered to more patients with refractory migraine, because certainly I think when you reach the end of therapies, sometimes there’s this thought that there’s nothing more to do.
And in the past, I think that was true. But there’s now more than, I guess, pure drug therapies. And that’s really amazing. I hope that trailblazers like Dr. Fiorella come up with more new things and roll this out more widely.
26:06: Closing Remarks
Timothy Brown
Perfect. And I’m so glad you’re willing to share your story because just even with what you were telling us about earlier, it’s great that somebody mentioned it to you. Otherwise you wouldn’t be here. We wouldn’t be having this conversation today and you wouldn’t be a patient of Dr. Fiorella’s.
So I think that’s really, really important. And so we’re hoping to get the word out to as many people as possible through this vehicle as well. So really, really appreciate both of you being on the program today.
That’s a wrap for this episode of Healthcast. We hope today’s conversation shed light on new possibilities for those struggling with treatment resistant migraines and highlighted the incredible innovations happening in neurointerventional care.
A huge thank you to Dr. Fiorella and Hayley for sharing their expertise and personal journeys with us. And of course, thank you to all of you for tuning in. If you enjoyed this episode, be sure to subscribe, leave a review and share it with someone who might find it helpful.
You can also follow us for more health insights and updates. Until next time, stay curious, stay informed and stay healthy.
Announcer
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