Butorphanol-midazolam combination therapy for the treatment of intracranial hypertension in a patient with tuberculous meningitis: a case study

INTRODUCTION: Intracranial hypertension, which often occurs in patients with tuberculous meningitis, is associated with high morbidity and mortality. We describe a patient with tuberculous meningitis who had intracranial hypertension -induced fulminant headache that responded to intravenous butorphanol-midazolam combination therapy. CASE PRESENTATION: A 50-year-old woman with a fever and headache for 24 days was given a diagnosis of tuberculous meningitis on the basis of the results of polymerase chain reaction amplification and Ziehl-Neelsen staining. Headache with vomiting developed despite administration of steroids, osmotic, and antituberculosis treatments. The patient was admitted in a confusional state. The initial pressure (420 mmHg) in cerebrospinal fluid was increased. She was given intravenous mannitol, dexamethasone, pentazocine and diazepam, or she was sedated with propofol, with no response. Next, a combination of butorphanol and midazolam was infused intravenously and finally resolved the confusional state. The initial pressure decreased, and she no longer complained of headache requiring medication. DISCUSSION AND EVALUATION: The butorphanol-midazolam combination therapy may have reduced intracranial pressure, leading to down-regulation of headache. Sedation induced by such combination of drugs was not accompanied by amnesia or impaired psychomotor function. CONCLUSIONS: The butorphanol-midazolam combination therapy might be an option for the management of intracranial hypertension in central nervous system infections.