|
1
|
Benoliel R, Sharav Y, Heiliczer S, Haviv Y. Orofacial Migraine and Neurovascular Orofacial Pain: Response to Treatment-A Pilot Study. Biomedicines 2025; 13:714. [PMID: 40149690 PMCID: PMC11940002 DOI: 10.3390/biomedicines13030714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2025] [Revised: 03/12/2025] [Accepted: 03/13/2025] [Indexed: 03/29/2025] Open
Abstract
Introduction: The International Classification of Orofacial Pain (ICOP) recognizes orofacial migraine (OFM) and neurovascular orofacial pain (NVOP) as migraine-related entities affecting the facial and oral regions. The diagnostic features of OFM and NVOP indicate that there are many similarities between the two. However, we recently demonstrated that NVOP and OFM are two distinct diagnostic entities, confirming the ICOP classification. It was the aim of the present study to examine whether OFM and NVOP differ in response to pharmacotherapy. Materials and Methods: The cohort was made up of 40 patients attending a tertiary orofacial pain clinic. When implementing ICOP criteria, an OFM diagnosis was made in 23 and an NVOP diagnosis in 17. Results: No statistically significant differences between NVOP versus OFM were observed in the global response to standard abortive therapy such as triptans, or NSAIDs. Similarly, no statistically significant differences were found following prophylactic therapy that included beta-blockers, anti-epileptic drugs, and tricyclic antidepressants. Up to 80% of patients responded favorably with ≥50% pain reduction. Conclusions: NVOP and OFM differ in diagnostic characteristics, demonstrating unique features, and were confirmed as two diagnostic entities. However, NVOP and OFM did not differ in their response to abortive or prophylactic treatments. Study limitations include the lack of starting data precluding a more precise pharmacological analysis. The small sample size limits any far reaching conclusions. This is particularly true regarding individual drug efficacy. We were unable to analyze drug and dose responses separately due to data constraints.
Collapse
Affiliation(s)
- Rafael Benoliel
- Department of Diagnostic Sciences, Rutgers School of Dental Medicine, Newark, NJ 07103, USA;
| | - Yair Sharav
- Department of Oral Medicine, Sedation and Imaging, Hadassah Medical Center, Faculty of Dental Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel;
| | - Shimrit Heiliczer
- Oral Medicine Unit, Oral and Maxillofacial Surgery Department, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel;
| | - Yaron Haviv
- Department of Oral Medicine, Sedation and Imaging, Hadassah Medical Center, Faculty of Dental Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel;
| |
Collapse
|
|
2
|
Benzon HT, Elmofty D, Shankar H, Rana M, Chadwick AL, Shah S, Souza D, Nagpal AS, Abdi S, Rafla C, Abd-Elsayed A, Doshi TL, Eckmann MS, Hoang TD, Hunt C, Pino CA, Rivera J, Schneider BJ, Stout A, Stengel A, Mina M, FitzGerald JD, Hirsch JA, Wasan AD, Manchikanti L, Provenzano DA, Narouze S, Cohen SP, Maus TP, Nelson AM, Shanthanna H. Use of corticosteroids for adult chronic pain interventions: sympathetic and peripheral nerve blocks, trigger point injections - guidelines from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, and the International Pain and Spine Intervention Society. Reg Anesth Pain Med 2025:rapm-2024-105593. [PMID: 39019502 DOI: 10.1136/rapm-2024-105593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 06/14/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND There is potential for adverse events from corticosteroid injections, including increase in blood glucose, decrease in bone mineral density and suppression of the hypothalamic-pituitary axis. Published studies note that doses lower than those commonly injected provide similar benefit. METHODS Development of the practice guideline was approved by the Board of Directors of American Society of Regional Anesthesia and Pain Medicine with several other societies agreeing to participate. The scope of guidelines was agreed on to include safety of the injection technique (landmark-guided, ultrasound or radiology-aided injections); effect of the addition of the corticosteroid on the efficacy of the injectate (local anesthetic or saline); and adverse events related to the injection. Based on preliminary discussions, it was decided to structure the topics into three separate guidelines as follows: (1) sympathetic, peripheral nerve blocks and trigger point injections; (2) joints; and (3) neuraxial, facet, sacroiliac joints and related topics (vaccine and anticoagulants). Experts were assigned topics to perform a comprehensive review of the literature and to draft statements and recommendations, which were refined and voted for consensus (≥75% agreement) using a modified Delphi process. The United States Preventive Services Task Force grading of evidence and strength of recommendation was followed. RESULTS This guideline deals with the use and safety of corticosteroid injections for sympathetic, peripheral nerve blocks and trigger point injections for adult chronic pain conditions. All the statements and recommendations were approved by all participants after four rounds of discussion. The Practice Guidelines Committees and Board of Directors of the participating societies also approved all the statements and recommendations. The safety of some procedures, including stellate blocks, lower extremity peripheral nerve blocks and some sites of trigger point injections, is improved by imaging guidance. The addition of non-particulate corticosteroid to the local anesthetic is beneficial in cluster headaches but not in other types of headaches. Corticosteroid may provide additional benefit in transverse abdominal plane blocks and ilioinguinal/iliohypogastric nerve blocks in postherniorrhaphy pain but there is no evidence for pudendal nerve blocks. There is minimal benefit for the use of corticosteroids in trigger point injections. CONCLUSIONS In this practice guideline, we provided recommendations on the use of corticosteroids in sympathetic blocks, peripheral nerve blocks, and trigger point injections to assist clinicians in making informed decisions.
Collapse
Affiliation(s)
- Honorio T Benzon
- Anesthesiology, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dalia Elmofty
- Department of Anesthesia, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Hariharan Shankar
- Anesthesiology, Clement Zablocki VA Medical Center/Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Maunak Rana
- Department of Anesthesia, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Andrea L Chadwick
- Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Shalini Shah
- University of California Irvine, Orange, California, USA
| | - Dmitri Souza
- Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| | - Ameet S Nagpal
- Orthopaedics and PM&R, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Salahadin Abdi
- Pain Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Christian Rafla
- Anesthesiology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Alaa Abd-Elsayed
- University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Tina L Doshi
- Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Maxim S Eckmann
- Anesthesiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Thanh D Hoang
- Endocrinology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | | | - Carlos A Pino
- Anesthesiology, Naval Medical Center San Diego, San Diego, California, USA
| | | | - Byron J Schneider
- PM&R, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Angela Stengel
- American Society of Regional Anesthesia and Pain Medicine, Pittsburgh, Pennsylvania, USA
| | - Maged Mina
- Anesthesiology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | | | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ajay D Wasan
- University of Pittsburgh Health Sciences, Pittsburgh, Pennsylvania, USA
| | | | | | - Samer Narouze
- Anesthesia, Division of Pain Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Steven P Cohen
- Anesthesiology, Feinberg School of Medicine, Chicago, Illinois, USA
- Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | | | - Ariana M Nelson
- Department of Anesthesiology and Perioperative Medicine, University of California Irvine, Irvine, California, USA
- Department of Aerospace Medicine, Exploration Medical Capability, Johnson Space Center
| | | |
Collapse
|
|
3
|
Fogh-Andersen IS, Petersen AS, Jensen RH, Sørensen JCH, Meier K. Transcutaneous electrical nerve stimulation of the occipital nerves as treatment for chronic cluster headache. Headache 2024. [PMID: 39703191 DOI: 10.1111/head.14889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2024] [Revised: 11/17/2024] [Accepted: 11/20/2024] [Indexed: 12/21/2024]
Abstract
BACKGROUND Chronic cluster headache (CCH) is an excruciatingly painful condition that can be difficult to treat sufficiently with the available medical treatment options. The greater occipital nerves (GON) are of major interest in treating CCH, and various invasive treatment modalities, such as stimulating or blocking the nerves, have been applied. Because the terminal segment of the GON has a superficial course, the nerve is also accessible for non-invasive transcutaneous stimulation. Transcutaneous electrical nerve stimulation (TENS) has been suggested as a treatment for different chronic headaches, but evidence of the efficacy in patients with CCH is scarce. Additionally, no consensus exists on the optimal placement of the transcutaneous stimulation electrodes or the treatment usage pattern. METHODS In this explorative open-label clinical study, 36 patients with CCH were treated with TENS of the GON for 8-12 consecutive weeks between August 2021 and October 2023 as a separate part of the study protocol for a trial on stimulation of the GON (Clinicaltrials.gov identifier: NCT05023460). After a baseline period, TENS was used primarily as a preventive treatment, stimulating for 30 min twice daily at a minimum. The primary outcome was a change in attack frequency and safety with TENS treatment. Secondary outcomes were change in attack duration and pain intensity on the numeric rating scale, abortive treatments, and the Patient Global Impression of Change (PGIC) with TENS treatment. The change in attack frequency, duration, pain intensity, and use of abortive treatment was analyzed by comparing the baseline data with 4-weekly data from TENS treatment. The study aimed to systematically investigate the effect of TENS of the GON as a preventive treatment for CCH. RESULTS Weekly attack frequency decreased from a median of 15.7 (95% confidence interval [CI] 11.2-22.1) at baseline to 11.0 (95% CI 7.4-16.4) with TENS. In all, 13 of the 36 (36%) patients had a minimum 30% reduction in attack frequency. In the group of 30% responders, the number of weekly attacks decreased from 15.8 (95% CI 9.8-24.5) at baseline to 5.8 (95% CI 3.3-10.5) attacks with TENS. Five patients became entirely or nearly attack-free. For the entire cohort, attack duration and pain intensity were also significantly reduced with TENS. The use of oxygen was reduced by 42%, and triptan injections decreased by 55%. Overall, 15 (42%) patients reported a clinically important improvement with TENS treatment, rated on the PGIC scale. The 100 Hz stimulation programs were preferred over 10 Hz. No serious adverse events were registered. CONCLUSION Transcutaneous electrical nerve stimulation of the GON significantly reduced the frequency, intensity, and duration of weekly headache attacks in patients with severe CCH. Not all patients benefitted from TENS, but the treatment responders had a substantial improvement in their cluster headache. TENS treatment was well-tolerated with little or no side effects and could be a relevant supplement to conventional preventive treatment. A standard TENS apparatus is low cost, making the treatment accessible to most patients. This paper includes a detailed, comprehensive description of our clinical application of the therapy.
Collapse
Affiliation(s)
- Ida Stisen Fogh-Andersen
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
- Center for Experimental Neuroscience (CENSE), Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anja Sofie Petersen
- Danish Headache Centre, Rigshospitalet-Glostrup, Copenhagen University Hospital, Copenhagen, Denmark
| | - Rigmor Højland Jensen
- Danish Headache Centre, Rigshospitalet-Glostrup, Copenhagen University Hospital, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jens Christian Hedemann Sørensen
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
- Center for Experimental Neuroscience (CENSE), Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Kaare Meier
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
- Center for Experimental Neuroscience (CENSE), Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|
|
4
|
Yang FC, Tsai CL, Lin GY, Yang CP, Chen WT. Acute and preventive medical treatment of cluster headache in Taiwan: A narrative review. J Chin Med Assoc 2024; 87:912-919. [PMID: 39129133 DOI: 10.1097/jcma.0000000000001148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/13/2024] Open
Abstract
Cluster headache (CH) is a debilitating neurological disorder characterized by severe, unilateral pain, and ipsilateral autonomic symptoms. Chronic CH is exceedingly rare in Taiwan, constituting approximately 1% of all CH cases. This narrative review provides an up-to-date overview of the acute and preventive treatment strategies for CH in Taiwan, focusing on currently available pharmacological options in the country. The treatment approach for CH in Taiwan involves a stepwise strategy. High-flow oxygen and triptan nasal sprays are the mainstays of acute treatment, providing rapid relief, and good tolerability. Transitional treatments, such as oral steroids and suboccipital steroid injections, serve as a crucial bridge between acute and long-term preventive therapies, offering temporary relief while minimizing side effects through a carefully limited duration. For preventive treatment, verapamil is the first-line option, with lithium and topiramate being the second-line alternatives. Among the calcitonin gene-related peptide (CGRP) monoclonal antibodies, galcanezumab has demonstrated efficacy in the prevention of episodic CH. Preventive treatments are personalized to individual patients, starting with low doses and close monitoring for adverse effects. Neuromodulatory therapies, such as noninvasive vagus nerve stimulation, show promise for chronic and refractory CH but have limited availability in Taiwan. In conclusion, despite the availability of various acute and preventive treatment options, unmet needs in the management of CH in Taiwan remain. In particular, increased awareness and education among healthcare professionals to improve the diagnosis and management of CH in Taiwan should be implemented.
Collapse
Affiliation(s)
- Fu-Chi Yang
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Chia-Lin Tsai
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Guan-Yu Lin
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Chun-Pai Yang
- Department of Neurology, Kuang Tien General Hospital, Taichung, Taiwan, ROC
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan, ROC
| | - Wei-Ta Chen
- Department of Neurology, Keelung Hospital, Ministry of Health and Welfare, Keelung, Taiwan, ROC
| |
Collapse
|
|
5
|
Benoliel R, May A. Orofacial Migraine-A Narrative Review. J Clin Med 2024; 13:5745. [PMID: 39407805 PMCID: PMC11476786 DOI: 10.3390/jcm13195745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2024] [Revised: 09/05/2024] [Accepted: 09/23/2024] [Indexed: 10/20/2024] Open
Abstract
The diagnosis of migraine is based on clear criteria outlined in the International Classification of Headache Disorders version 3 (ICHD-3). Notably, the criteria in ICHD-3 omit the location of the migraine. There are increasing reports of migraine in the facial region. Facial presentations of migraine are not easy to diagnose as they appear in the lower two-thirds of the face, often in the maxillary sinus region, around the ear, the upper/lower jaws, and the teeth. Additionally, a similar but distinct entity, neurovascular orofacial pain, has been established. The symptomatology of facial presentations of these headaches often resembles sinusitis and dental pathology. We will review these presentations, their diagnosis, and possible pathophysiology.
Collapse
Affiliation(s)
- Rafael Benoliel
- Department of Diagnostic Sciences, Rutgers School of Dental Medicine, Rutgers University, Newark, NJ 07103, USA
| | - Arne May
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany;
| |
Collapse
|
|
6
|
Simmonds L, Jamtøy KA, Aschehoug I, Hara S, Meisingset TW, Matharu MS, Tronvik E, Bratbak DF. Open label experience of repeated OnabotulinumtoxinA injections towards the sphenopalatine ganglion in patients with chronic cluster headache and chronic migraine. Cephalalgia 2024; 44:3331024241273967. [PMID: 39165124 DOI: 10.1177/03331024241273967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2024]
Abstract
BACKGROUND A novel technique for injection of OnabotulinumtoxinA (BTA) towards the sphenopalatine ganglion (SPG) has shown promise in refractory chronic migraine (CM) and chronic cluster headache (CCH). Open label safety and efficacy data are presented here. METHODS Patients with refractory CM or CCH who had received at least one injection and completed headache diaries were included. Efficacy was defined as ≥50% reduction in moderate-to-severe headache days for CM, or ≥50% reduction in attack frequency for CCH, at weeks five to eight. RESULTS Over 261 injections, there were 123 adverse events (AE), of which one was serious. Most (93%) AEs were mild and all were transient. The 50% response to one injection was 81% for CM and 69% for CCH. The response gradually reduced over subsequent months for CM but stayed between 55% and 67% for CCH. Repeated injections were beneficial. CONCLUSIONS Injections resulted in improvement for both groups and was maintained with repeated injections. Repeat injection after three months may be beneficial in CM. Adverse events were not uncommon, but universally transient, presumably as a result of the mechanism of action of BTA. Repeated BTA injection towards the SPG could be an effective treatment for refractory CM and CCH. Larger, randomised, placebo-controlled trials are required.
Collapse
Affiliation(s)
- Lucy Simmonds
- Headache and Facial Pain Group, University College London Queen Square Institute of Neurology, London, UK
- Headache and Facial Pain Group, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Kent Are Jamtøy
- Department of Neuromedicine and Movement Science, NTNU Norwegian University of Science and Technology, Trondheim, Norway
- Department of Maxillofacial Surgery, St Olav's University Hospital, Trondheim, Norway
| | - Irina Aschehoug
- Department of Neuromedicine and Movement Science, NTNU Norwegian University of Science and Technology, Trondheim, Norway
| | - Sozaburo Hara
- Department of Neuromedicine and Movement Science, NTNU Norwegian University of Science and Technology, Trondheim, Norway
- Department of Neurosurgery, St Olav's University Hospital, Trondheim, Norway
| | - Tore W Meisingset
- Department of Neuromedicine and Movement Science, NTNU Norwegian University of Science and Technology, Trondheim, Norway
- NorHEAD, Norwegian Headache Research Centre, Norway
- National Advisory Unit on Headaches, Department of Neurology and Clinical Neurophysiology, St Olav's Hospital, Trondheim, Norway
| | - Manjit S Matharu
- Headache and Facial Pain Group, University College London Queen Square Institute of Neurology, London, UK
- Headache and Facial Pain Group, The National Hospital for Neurology and Neurosurgery, London, UK
- NorHEAD, Norwegian Headache Research Centre, Norway
| | - Erling Tronvik
- Department of Neuromedicine and Movement Science, NTNU Norwegian University of Science and Technology, Trondheim, Norway
- NorHEAD, Norwegian Headache Research Centre, Norway
- National Advisory Unit on Headaches, Department of Neurology and Clinical Neurophysiology, St Olav's Hospital, Trondheim, Norway
| | - Daniel Fossum Bratbak
- Department of Neuromedicine and Movement Science, NTNU Norwegian University of Science and Technology, Trondheim, Norway
- Department of Neurosurgery, St Olav's University Hospital, Trondheim, Norway
| |
Collapse
|
|
7
|
Schindler EAD, Sewell RA, Gottschalk CH, Flynn LT, Zhu Y, Pittman BP, Cozzi NV, D'Souza DC. Psilocybin pulse regimen reduces cluster headache attack frequency in the blinded extension phase of a randomized controlled trial. J Neurol Sci 2024; 460:122993. [PMID: 38581739 DOI: 10.1016/j.jns.2024.122993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/21/2024] [Accepted: 03/31/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND In a recent randomized, double-blind, placebo-controlled study, we observed a nonsignificant reduction of attack frequency in cluster headache after pulse administration of psilocybin (10 mg/70 kg, 3 doses, 5 days apart each). We carried out a blinded extension phase to consider the safety and efficacy of repeating the pulse regimen. METHODS Eligible participants returned to receive a psilocybin pulse at least 6 months after their first round of study participation. Participants kept headache diaries starting two weeks before and continuing through eight weeks after the first drug session. Ten participants completed the extension phase and all ten were included in the final analysis. RESULTS In the three weeks after the start of the pulse, cluster attack frequency was significantly reduced from baseline (18.4 [95% confidence interval 8.4 to 28.4] to 9.8 [4.3 to 15.2] attacks/week; p = 0.013, d' = 0.97). A reduction of approximately 50% was seen regardless of individual response to psilocybin in the first round. Psilocybin was well-tolerated without any unexpected or serious adverse events. DISCUSSION This study shows a significant reduction in cluster attack frequency in a repeat round of pulse psilocybin administration and suggests that prior response may not predict the effect of repeated treatment. To gauge the full potential of psilocybin as a viable medicine in cluster headache, future work should investigate the safety and therapeutic efficacy in larger, more representative samples over a longer time period, including repeating the treatment. CLINICAL TRIALS REGISTRATION NCT02981173.
Collapse
Affiliation(s)
- Emmanuelle A D Schindler
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States of America; Neurology Service, Veterans Affairs Connecticut Healthcare System, West Haven, CT, United States of America; Headache Center of Excellence, Veterans Affairs Connecticut Healthcare System, West Haven, CT, United States of America.
| | - R Andrew Sewell
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America; Psychiatry Service, Veterans Affairs Connecticut Healthcare System, West Haven, CT, United States of America
| | | | - L Taylor Flynn
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America; Psychiatry Service, Veterans Affairs Connecticut Healthcare System, West Haven, CT, United States of America
| | - Yutong Zhu
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America; Psychiatry Service, Veterans Affairs Connecticut Healthcare System, West Haven, CT, United States of America
| | - Brian P Pittman
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America
| | - Nicholas V Cozzi
- Neuropharmacology Laboratory, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States of America; Alexander Shulgin Research Institute, Lafayette, CA, United States of America
| | - Deepak C D'Souza
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America; Psychiatry Service, Veterans Affairs Connecticut Healthcare System, West Haven, CT, United States of America
| |
Collapse
|
|
8
|
Saglam L, Gayretli O, Coskun O, Kale A. Morphological features of the greater occipital nerve and its possible importance for interventional procedures. J Anat 2024; 244:312-324. [PMID: 37777340 PMCID: PMC10780152 DOI: 10.1111/joa.13959] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/18/2023] [Accepted: 09/18/2023] [Indexed: 10/02/2023] Open
Abstract
Being one of the most prevalent neurological symptoms, headaches are burdensome and costly. Blocks and decompression surgeries of the greater occipital nerve (GON) have been frequently used for migraine, cervicogenic headache, and occipital neuralgia which are classified under headache by International Headache Society. Knowledge of complex anatomy of GON is crucial for its decompression surgery and block. This study was performed to elucidate anatomical features of this nerve in detail. Forty-one cadavers were dissected bilaterally. According to its morphological features, GON was classified into four main types that included 18 subtypes. Moreover, potential compression points of the nerve were defined. The number of branches of the GON up to semispinalis capitis muscle and the number of its branches that were sent to this muscle were recorded. The most common variant was that the GON pierced the aponeurosis of the trapezius muscle, curved around the lower edge of the obliquus capitis inferior muscle, and was loosely attached to the obliquus capitis inferior muscle (Type 2; 61 sides, 74.4%). In the subtypes, the most common form was Type 2-A (44 sides, 53.6%), in which the GON pierced the aponeurosis of each of the trapezius muscle and fibers of semispinalis muscle at one point and there was a single crossing of the GON and occipital artery. Six potential compression points of the GON were detected. The first point was where the nerve crossed the lower border of the obliquus capitis inferior muscle. The second and third points were at its piercing of the semispinalis capitis muscle and the muscle fibers/aponeurosis of the trapezius, respectively. Fourth, fifth, and sixth compression points of GON were located where the GON and occipital artery crossed each other for the first, second, and third times, respectively. On 69 sides, 1-4 branches of the GON up to the semispinalis capitis muscle were observed (median = 1), while 1-4 branches of GON were sent to the semispinalis capitis muscle on 67 sides (median = 1). The novel anatomical findings described in this study may play a significant role in increasing the success rate of invasive interventions related with the GON.
Collapse
Affiliation(s)
- Latif Saglam
- Department of Anatomy, Istanbul Faculty of MedicineIstanbul UniversityIstanbulTurkey
| | - Ozcan Gayretli
- Department of Anatomy, Istanbul Faculty of MedicineIstanbul UniversityIstanbulTurkey
| | - Osman Coskun
- Department of Anatomy, Istanbul Faculty of MedicineIstanbul UniversityIstanbulTurkey
| | - Aysin Kale
- Department of Anatomy, Istanbul Faculty of MedicineIstanbul UniversityIstanbulTurkey
| |
Collapse
|
|
9
|
Fabry A, Nedunchelian M, Stacoffe N, Guinebert S, Zipfel J, Krainik A, Maindet C, Kastler B, Grand S, Kastler A. Review of craniofacial pain syndromes involving the greater occipital nerve: relevant anatomy, clinical findings, and interventional management. Neuroradiology 2024; 66:161-178. [PMID: 38159141 DOI: 10.1007/s00234-023-03273-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 12/19/2023] [Indexed: 01/03/2024]
Abstract
Craniofacial pain syndromes exhibit a high prevalence in the general population, with a subset of patients developing chronic pain that significantly impacts their quality of life and results in substantial disabilities. Anatomical and functional assessments of the greater occipital nerve (GON) have unveiled its implication in numerous craniofacial pain syndromes, notably through the trigeminal-cervical convergence complex. The pathophysiological involvement of the greater occipital nerve in craniofacial pain syndromes, coupled with its accessibility, designates it as the primary target for various interventional procedures in managing craniofacial pain syndromes. This educational review aims to describe multiple craniofacial pain syndromes, elucidate the role of GON in their pathophysiology, detail the relevant anatomy of the greater occipital nerve (including specific intervention sites), highlight the role of imaging in diagnosing craniofacial pain syndromes, and discuss various interventional procedures such as nerve infiltration, ablation, neuromodulation techniques, and surgeries. Imaging is essential in managing these patients, whether for diagnostic or therapeutic purposes. The utilization of image guidance has demonstrated an enhancement in reproducibility, as well as technical and clinical outcomes of interventional procedures. Studies have shown that interventional management of craniofacial pain is effective in treating occipital neuralgia, cervicogenic headaches, cluster headaches, trigeminal neuralgia, and chronic migraines, with a reported efficacy of 60-90% over a duration of 1-9 months. Repeated infiltrations, neuromodulation, or ablation may prove effective in selected cases. Therefore, reassessment of treatment response and efficacy during follow-up is imperative to guide further management and explore alternative treatment options. Optimal utilization of imaging, interventional techniques, and a multidisciplinary team, including radiologists, will ensure maximum benefit for these patients.
Collapse
Affiliation(s)
- Alienor Fabry
- Neuroradiology Unit, University Hospital, Grenoble, France
| | | | | | | | | | | | | | - Bruno Kastler
- Radiology Unit, Necker University Hospital, Paris, France
| | - Sylvie Grand
- Neuroradiology Unit, University Hospital, Grenoble, France
| | - Adrian Kastler
- Neuroradiology Unit, University Hospital, Grenoble, France.
| |
Collapse
|
|
10
|
Gordon A, Roe T, Villar-Martínez MD, Moreno-Ajona D, Goadsby PJ, Hoffmann J. Effectiveness and safety profile of greater occipital nerve blockade in cluster headache: a systematic review. J Neurol Neurosurg Psychiatry 2023; 95:73-85. [PMID: 36948579 DOI: 10.1136/jnnp-2023-331066] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 03/07/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Greater occipital nerve (GON) blockade is a short-term preventive therapy for cluster headache (CH). We conducted a systematic review to evaluate the effectiveness and safety of GON blockade in patients with CH. METHODS On 23 October 2020, we searched MEDLINE, Embase, Embase Classic, PsycINFO, CINAHL, CENTRAL and Web of Science databases from their inception date. Studies included participants with a CH diagnosis who received corticosteroid and local anaesthetic suboccipital region injections. Outcomes were change in the frequency/severity/duration of attacks; proportion of participants responding to treatment, time to attack freedom from an attack, change in attack bout length and/or the presence of adverse effects after GON blockade. Risk of bias was assessed with the Cochrane Risk of Bias V.2.0 (RoB2)/Risk of Bias in Non-randomized Studies - of Interventions (ROBINS- I) tools and a specific tool for case reports/series. RESULTS Two RCTs, eight prospective and eight retrospective studies, and four case reports were included in the narrative synthesis. Every effectiveness study found a significant response in one or more of frequency/severity/duration of individual attacks or proportion of patients responding to treatment (47.8%-100.0%). There were five instances of potentially irreversible adverse effects. A higher injectate volume and use of concurrent prophylaxis may be associated with an increased likelihood of response. Methylprednisolone may have the best safety profile of available corticosteroids. DISCUSSION GON blockade is safe and effective for CH prevention. Higher injectate volumes may improve likelihood of response, and the likelihood of serious adverse events may be reduced by using methylprednisolone. PROSPERO REGISTRATION NUMBER CRD42020208435.
Collapse
Affiliation(s)
- Alexander Gordon
- Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - Thomas Roe
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - María Dolores Villar-Martínez
- Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- NIHR-Wellcome Trust King's Clinical Research Facility/SLaM Biomedical Research Centre, King's College Hospital, London, UK
| | - David Moreno-Ajona
- Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- NIHR-Wellcome Trust King's Clinical Research Facility/SLaM Biomedical Research Centre, King's College Hospital, London, UK
| | - Peter J Goadsby
- Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- NIHR-Wellcome Trust King's Clinical Research Facility/SLaM Biomedical Research Centre, King's College Hospital, London, UK
| | - Jan Hoffmann
- Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- NIHR-Wellcome Trust King's Clinical Research Facility/SLaM Biomedical Research Centre, King's College Hospital, London, UK
| |
Collapse
|
|
11
|
Fogh-Andersen IS, Sørensen JCH, Jensen RH, Knudsen AL, Meier K. Treatment of chronic cluster headache with burst and tonic occipital nerve stimulation: A case series. Headache 2023; 63:1145-1153. [PMID: 37602914 DOI: 10.1111/head.14617] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 07/10/2023] [Accepted: 07/14/2023] [Indexed: 08/22/2023]
Abstract
OBJECTIVES AND BACKGROUND Chronic cluster headache (CCH) is a rare but severely debilitating primary headache condition. A growing amount of evidence suggests that occipital nerve stimulation (ONS) can offer effective treatment in patients with severe CCH for whom conventional medical therapy does not have a sufficient effect. The paresthesia evoked by conventional (tonic) stimulation can be bothersome and may thus limit therapy. Burst ONS produces paresthesia-free stimulation, but the amount of evidence on the efficacy of burst ONS as a treatment for intractable CCH is scarce. METHODS In this case series, we report 15 patients with CCH treated with ONS at Aarhus University Hospital, Denmark, from 2013 to 2020. Nine of these received burst stimulation either as primary treatment or as a supplement to tonic stimulation. The results were assessed in terms of the frequency of headache attacks per week and their intensity on the Numeric Rating Scale, as well as the Patient Global Impression of Change (PGIC) with ONS treatment. RESULTS At a median (range) follow-up of 38 (16-96) months, 12 of the 15 patients (80%) reported a reduction in attack frequency of ≥50% (a reduction from a median of 35 to 1 attack/week, p < 0.001). Seven of these patients were treated with burst ONS. A significant reduction was also seen in maximum pain intensity. Overall, 10 patients stated a clinically important improvement in their headache condition following ONS treatment, rated on the PGIC scale. A total of 16 adverse events (nine of which were in the same patient) were registered. CONCLUSION Occipital nerve stimulation significantly reduced the number of weekly headache attacks and their intensity. Burst ONS seems to function well alone or as a supplement to conventional tonic ONS as a preventive treatment for CCH; however, larger prospective studies are needed to determine whether the effect can be confirmed and whether the efficacy of the two stimulation paradigms is even.
Collapse
Affiliation(s)
- Ida Stisen Fogh-Andersen
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
- Center for Experimental Neuroscience (CENSE), Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jens Christian Hedemann Sørensen
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
- Center for Experimental Neuroscience (CENSE), Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Rigmor Højland Jensen
- Danish Headache Centre, Righospitalet-Glostrup, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Denmark
| | - Anne Lene Knudsen
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
| | - Kaare Meier
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
- Center for Experimental Neuroscience (CENSE), Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|
|
12
|
Peng KP, Burish MJ. Management of cluster headache: Treatments and their mechanisms. Cephalalgia 2023; 43:3331024231196808. [PMID: 37652457 DOI: 10.1177/03331024231196808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
BACKGROUND The management of cluster headache is similar to that of other primary headache disorders and can be broadly divided into acute and preventive treatments. Acute treatments for cluster headache are primarily delivered via rapid, non-oral routes (such as inhalation, nasal, or subcutaneous) while preventives include a variety of unrelated treatments such as corticosteroids, verapamil, and galcanezumab. Neuromodulation is becoming an increasingly popular option, both non-invasively such as vagus nerve stimulation when medical treatment is contraindicated or side effects are intolerable, and invasively such as occipital nerve stimulation when medical treatment is ineffective. Clinically, this collection of treatment types provides a range of options for the informed clinician. Scientifically, this collection provides important insights into disease mechanisms. METHODS Two authors performed independent narrative reviews of the literature on guideline recommendations, clinical trials, real-world data, and mechanistic studies. RESULTS Cluster headache is treated with acute treatments, bridge treatments, and preventive treatments. Common first-line treatments include subcutaneous sumatriptan and high-flow oxygen as acute treatments, corticosteroids (oral or suboccipital injections) as bridge treatments, and verapamil as a preventive treatment. Some newer acute (non-invasive vagus nerve stimulation) and preventive (galcanezumab) treatments have excellent clinical trial data for episodic cluster headache, while other newer treatments (occipital nerve stimulation) have been specifically tested in treatment-refractory chronic cluster headache. Most treatments are suspected to act on the trigeminovascular system, the autonomic system, or the hypothalamus. CONCLUSIONS The first-line treatments have not changed in recent years, but new treatments have provided additional options for patients.
Collapse
Affiliation(s)
- Kuan-Po Peng
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mark J Burish
- Department of Neurosurgery, UTHealth Houston, Houston, Texas, USA
| |
Collapse
|
|
13
|
Castillo-Álvarez F, Hernando de la Bárcena I, Marzo-Sola ME. Greater occipital nerve block in the treatment of headaches. Review of evidence. Med Clin (Barc) 2023:S0025-7753(23)00177-X. [PMID: 37100680 DOI: 10.1016/j.medcli.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/01/2023] [Accepted: 04/04/2023] [Indexed: 04/28/2023]
Abstract
INTRODUCTION Peripheral nerve blocks have been a common treatment for multiple headaches. By far, the greater occipital nerve block is the most used and with the stronger body of evidence in routine clinical practice. METHODS We searched Pubmed Meta-Analysis/Systematic Review, in the last 10 years. Of these results, meta-analyses, and in the absence of these systematic reviews, assessing Greater Occipital Nerve Block in headache has been selected for review. RESULTS We identified 95 studies in Pubmed, 13 that met the inclusion criteria. CONCLUSION Greater occipital block is an effective and safe technique, easy to perform and which has shown its usefulness in migraine, cluster headache, cervicogenic headache and Post-dural puncture headache. However, more studies are needed to clarify its long-term efficacy, its place in clinical treatment, the possible difference between different anaesthetics, the most convenient dosage and the role of concomitant use of corticosteroids.
Collapse
|
|
14
|
Aggarwal AK, Ottestad E, Pfaff KE, Huai-Yu Li A, Xu L, Derby R, Hecht D, Hah J, Pritzlaff S, Prabhakar N, Krane E, D’Souza G, Hoydonckx Y. Review of Ultrasound-Guided Procedures in the Management of Chronic Pain. Anesthesiol Clin 2023; 41:395-470. [DOI: 10.1016/j.anclin.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
|
|
15
|
Sharav Y, Haviv Y, Benoliel R. Orofacial Migraine or Neurovascular Orofacial Pain from Pathogenesis to Treatment. Int J Mol Sci 2023; 24:2456. [PMID: 36768779 PMCID: PMC9917018 DOI: 10.3390/ijms24032456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/21/2023] [Accepted: 01/25/2023] [Indexed: 01/28/2023] Open
Abstract
The purpose of the present study is to examine possible differences between orofacial migraine (OFM) and neurovascular orofacial pain (NVOP). Facial presentations of primary headache are comparable to primary headache disorders; but occurring in the V2 or V3 dermatomes of the trigeminal nerve. These were classified and recently published in the International Classification of Orofacial Pain, 1st edition (ICOP). A category in this classification is "orofacial pains resembling presentations of primary headaches," which encompasses OFM and NVOP. The differences between NVOP and OFM are subtle, and their response to therapy may be similar. While classified under two separate entities, they contain many features in common, suggesting a possible overlap between the two. Consequently, their separation into two entities warrants further investigations. We describe OFM and NVOP, and their pathophysiology is discussed. The similarities and segregating clinical signs and symptoms are analyzed, and the possibility of unifying the two entities is debated.
Collapse
Affiliation(s)
- Yair Sharav
- Department of Oral Medicine, Sedation & Maxillofacial Imaging, School of Dental Medicine, Hebrew University-Hadassah, Jerusalem 91010, Israel
| | - Yaron Haviv
- Department of Oral Medicine, Sedation & Maxillofacial Imaging, School of Dental Medicine, Hebrew University-Hadassah, Jerusalem 91010, Israel
| | - Rafael Benoliel
- Unit for Oral Medicine, Department of Oral and Maxillofacial Surgery Division of ENT, Head & Neck and Oral and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center-Ichilov, Tel Aviv 61060, Israel
| |
Collapse
|
|
16
|
Stern JI, Chiang C, Kissoon NR, Robertson CE. Narrative review of peripheral nerve blocks for the management of headache. Headache 2022; 62:1077-1092. [DOI: 10.1111/head.14385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 06/21/2022] [Accepted: 07/18/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Jennifer I. Stern
- Headache Division, Department of Neurology Mayo Clinic Rochester Minnesota USA
| | - Chia‐Chun Chiang
- Headache Division, Department of Neurology Mayo Clinic Rochester Minnesota USA
| | - Narayan R. Kissoon
- Headache Division, Department of Neurology Mayo Clinic Rochester Minnesota USA
- Division of Pain Medicine, Department of Anesthesiology Mayo Clinic Rochester Minnesota USA
| | - Carrie E. Robertson
- Headache Division, Department of Neurology Mayo Clinic Rochester Minnesota USA
| |
Collapse
|
|
17
|
Peng KP, Benoliel R, May A. A Review of Current Perspectives on Facial Presentations of Primary Headaches. J Pain Res 2022; 15:1613-1621. [PMID: 35685300 PMCID: PMC9174019 DOI: 10.2147/jpr.s294404] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 05/30/2022] [Indexed: 11/23/2022] Open
Abstract
Orofacial pain (OFP) has recently been classified and subdivided into a number of groups, similar to headache disorders in the International Classification of Headache Disorders (ICHD). A novel group of OFP has been established whose major feature is that they resemble primary headache disorders occurring in the V2 or V3 dermatomes. These follow the clinical criteria and associated symptoms of the eponymous headache syndromes. Following the recent International Classification of Orofacial Pain (ICOP), three types are differentiated: Headache which spread into the face (type 1), facial pain which replaced headache but maintained the same characteristics and associated symptoms of the former headache (type 2), and de-novo orofacial pain that resembles primary headache types without any involvement of the ophthalmic trigeminal branch (type 3). The epidemiology is unclear: type 1 and 2 are not exactly common, they certainly exist in a notable proportion of headache patients, whereas type 3 may be rather rare. Since effective treatment options are available, it is important for clinicians to recognize such syndromes early to avoid misdiagnosis and unnecessary treatment, which most of these patients still experience. This review gives an up-to-date summary of diagnosis, pathophysiology and treatment of attack-like non-dental facial pain disorders.
Collapse
Affiliation(s)
- Kuan-Po Peng
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rafael Benoliel
- Department of Diagnostic Sciences, Rutgers School of Dental Medicine, Rutgers University, Newark, NJ, USA
| | - Arne May
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Correspondence: Arne May, Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246, Hamburg, Germany, Tel +49-40-7410-59189, Fax +49-40-7410-59955, Email
| |
Collapse
|
|
18
|
Prasad S, Mehadi A, Kaka N, Jhaveri S, Avanthika C, Patel N, Augustine I, Issani A. Diagnostic protocols and newer treatment modalities for cluster headache. Dis Mon 2022; 68:101316. [PMID: 35000758 DOI: 10.1016/j.disamonth.2021.101316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Cluster Headaches are one of the most arguably severe forms of primary headache syndrome that affects humans. Although it is relatively uncommon, it has a significant impact on the quality of life. It is a multifactorial disease that has risk factors ranging from seasonal changes, lifestyle habits to genetics. It occurs in 2 forms- Episodic and Chronic, each having its well-defined Diagnostic Criteria. Moreover, Cluster Headache has an exhaustive list of options for both Preventive and Abortive treatment. This article focuses on Cluster Headache, its pathophysiology, risk factors, differentials, and its diverse treatment modalities. In this study, an all-language literature search was conducted on Medline, Cochrane, Embase, and Google Scholar till October 2021. The following search strings and Medical Subject Headings (MeSH) terms were used: "Cluster Headache," "Triptans," "Neuromodulation," and "Migraine." We explored the literature on Cluster Headache for its epidemiology, pathophysiology, the role of various genes and how they bring about the disease as well as its episodic and chronic variants, and treatment options. Although we have a wide variety of options for Preventive and Abortive therapy, newer more effective pharmacological and non-pharmacological interventions are being developed, and must be integrated into new treatment protocols.
Collapse
Affiliation(s)
- Sakshi Prasad
- Faculty of Medicine, National Pirogov, Memorial Medical University, 21018, Vinnytsya, Ukraine.
| | | | - Nirja Kaka
- GMERS Medical College, Himmatnagar 383001, Gujarat, India.
| | - Sharan Jhaveri
- Smt. NHL Municipal Medical college, Ahmedabad 380006, India.
| | - Chaithanya Avanthika
- Karnataka Institute of Medical Sciences,PB Road, Hubli 580022, Karnataka, India.
| | - Neil Patel
- GMERS Medical College, Himmatnagar 383001, Gujarat, India.
| | - Ivan Augustine
- Government Medical college Thrissur 680596, Kerala,India.
| | - Ali Issani
- Baqai Medical University, Karachi, Pakistan.
| |
Collapse
|
|
19
|
Great occipital nerve long-acting steroid injections in cluster headache therapy: an observational prospective study. J Neurol 2021; 269:2193-2199. [PMID: 34820736 PMCID: PMC8940833 DOI: 10.1007/s00415-021-10884-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/30/2021] [Accepted: 11/01/2021] [Indexed: 11/25/2022]
Abstract
Background Injections targeting the occipital nerve are used to reduce headache attacks and abort cluster bouts in cluster headache patients. There is no widely accepted agreement over the optimal technique of injection, type and doses of steroids and/or anesthetics to use, as well as injection regimens. The aim of this study was to verify the effectiveness and safety of greater occipital nerve long-acting steroid injections in the management of episodic and chronic cluster headache. Methods We conducted a prospective observational cohort study on episodic (ECH) and chronic cluster headache patients (CCH). ECH were included in the study at the beginning of a cluster period. Three injections with 60 mg methylprednisolone were performed on alternate days. We registered the frequency and intensity of attacks three days before and 3, 7 and 30 days after the treatment, the latency of cluster relapse, adverse events, scores evaluating anxiety (Zung scale), depression (Beck’s Depression Scale) and quality of life (Disability Assessment Schedule II, 12-Item Self-Administered Version). Primary outcome was the interruption of the cluster after the three injections. Responders conducted a follow-up period of 12 months. Results We enrolled 60 patients, 47 with ECH and 13 with CCH. We observed a complete response in 47.8% (22/46) of episodic and 33.3% (4/12) of chronic patients. Moreover, a partial response (reduction of at least 50% of attacks) was obtained in further 10.8% (5/46) of episodic and in 33.3% (4/12) of chronic patients at 1 month. Median pain-free period was of 3 months for CCH responders. Only mild adverse events were reported in 38.3% (23/58) cases. Conclusions We suggest three greater occipital nerve injections of 60 mg methylprednisolone on alternate days as useful therapy in episodic and chronic cluster headache. This leads to a long pain-free period in chronic forms. Adverse effects are mild and support its use as first choice. Trial registration The study was inserted in AIFA observational studies register. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-021-10884-0.
Collapse
|
|
20
|
Batistaki C, Madi AI, Karakosta A, Kostopanagiotou G, Arvaniti C. Pulsed Radiofrequency of the Occipital Nerves: Results of a Standardized Protocol on Chronic Headache Management. Anesth Pain Med 2021; 11:e112235. [PMID: 35075408 PMCID: PMC8782194 DOI: 10.5812/aapm.112235] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 08/28/2021] [Accepted: 08/30/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Pulsed radiofrequency (PRF) of the occipital nerves has neuromodulative properties and is used for chronic pain management. However, its role in various types of chronic headaches has not been adequately investigated so far. OBJECTIVES Τhis was an observational, open-label, prospective study aiming to assess the efficacy of PRF of occipital nerves on various types of chronic headache management. METHODS Patients with chronic headaches followed up at the pain management unit were scheduled for PRF of both occipital nerves after a positive diagnostic nerve block. PRF was applied following a standardized protocol at 42°C, and the number of headaches per month was assessed as a primary outcome at baseline (before treatment), as well as after 1, 3, and 6 months. Pain intensity during headache crises was recorded using the Numeric Rating Scale (NRS, 0 - 10). RESULTS Fifty-seven patients suffering from chronic migraines, cluster headaches, tension-type headaches, and occipital neuralgia were studied. PRF significantly improved the number of headache episodes per month, as well as the pain intensity of the crises. The median number of headache episodes per month was significantly reduced in patients with migraine, from 14.5 to 4 after 1 month, and to 6.5 after 6 months. The same was seen for patients with clusters, who were also improved. A statistically significant reduction in NRS values over time was seen for all types of headaches. CONCLUSIONS PRF of the occipital nerves can lead to a reduction of the number of headache episodes per month, improving the intensity of pain during each episode.
Collapse
Affiliation(s)
- Chrysanthi Batistaki
- 2nd Department of Anaesthesiology, School of Medicine, National and Kapodistrian University of Athens, Attikon Hospital, Athens, Greece
| | - Alia Ibrahim Madi
- 2nd Department of Anaesthesiology, School of Medicine, National and Kapodistrian University of Athens, Attikon Hospital, Athens, Greece
| | - Agathi Karakosta
- 2nd Department of Anaesthesiology, School of Medicine, National and Kapodistrian University of Athens, Attikon Hospital, Athens, Greece
| | - Georgia Kostopanagiotou
- 2nd Department of Anaesthesiology, School of Medicine, National and Kapodistrian University of Athens, Attikon Hospital, Athens, Greece
| | - Chrysa Arvaniti
- 2nd Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Attikon Hospital, Athens, Greece
| |
Collapse
|
|
21
|
Medina S, Bakar NA, O'Daly O, Miller S, Makovac E, Renton T, Williams SCR, Matharu M, Howard MA. Regional cerebral blood flow as predictor of response to occipital nerve block in cluster headache. J Headache Pain 2021; 22:91. [PMID: 34384347 PMCID: PMC8359299 DOI: 10.1186/s10194-021-01304-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/30/2021] [Indexed: 01/03/2023] Open
Abstract
Background Cluster headache is an excruciating disorder with no cure. Greater occipital nerve blockades can transiently suppress attacks in approximately 50% of patients, however, its mechanism of action remains uncertain, and there are no reliable predictors of treatment response. To address this, we investigated the effect of occipital nerve blockade on regional cerebral blood flow (rCBF), an index of brain activity, and differences between treatment responders and non-responders. Finally, we compared baseline perfusion maps from patients to a matched group of healthy controls. Methods 21 male, treatment-naive patients were recruited while in a cluster headache bout. During a pain-free phase between headaches, patients underwent pseudo-continuous arterial spin labelled MRI assessments to provide quantitative indices of rCBF. MRIs were performed prior to and 7-to-21 days following treatment. Patients also recorded the frequency of their headache attacks in a daily paper diary. Neuropsychological assessment including anxiety, depression and quality of life measures was performed in a first, scanning free session for each patient. Results Following treatment, patients demonstrated relative rCBF reductions in posterior temporal gyrus, cerebellum and caudate, and rCBF increases in occipital cortex. Responders demonstrated relative rCBF increases, compared to non-responders, in medial prefrontal cortex and lateral occipital cortex at baseline, but relative reductions in cingulate and middle temporal cortices. rCBF was increased in patients compared to healthy controls in cerebellum and hippocampus, but reduced in orbitofrontal cortex, insula and middle temporal gyrus. Conclusions We provide new mechanistic insights regarding the aetiology of cluster headache, the mechanisms of action of occipital nerve blockades and potential predictors of treatment response. Future investigation should determine whether observed effects are reproducible and extend to other headache disorders.
Collapse
Affiliation(s)
- Sonia Medina
- Department of Neuroimaging, King's College London, Institute of Psychiatry, Psychology and Neuroscience, Box 89, De Crespigny Park, London, SE5 8AF, UK. .,Wolfson Centre for Age-Related Diseases, King's College London, London, UK.
| | | | - Owen O'Daly
- Department of Neuroimaging, King's College London, Institute of Psychiatry, Psychology and Neuroscience, Box 89, De Crespigny Park, London, SE5 8AF, UK
| | - Sarah Miller
- Headache and Facial Pain Group, UCL Queen Square Institute of Neurology, Queen Square, London, UK
| | - Elena Makovac
- Department of Neuroimaging, King's College London, Institute of Psychiatry, Psychology and Neuroscience, Box 89, De Crespigny Park, London, SE5 8AF, UK.,Wolfson Centre for Age-Related Diseases, King's College London, London, UK
| | - Tara Renton
- Department of Oral Surgery, King's College London, London, UK
| | - Steve C R Williams
- Department of Neuroimaging, King's College London, Institute of Psychiatry, Psychology and Neuroscience, Box 89, De Crespigny Park, London, SE5 8AF, UK
| | - Manjit Matharu
- Headache and Facial Pain Group, UCL Queen Square Institute of Neurology, Queen Square, London, UK
| | - Matthew A Howard
- Department of Neuroimaging, King's College London, Institute of Psychiatry, Psychology and Neuroscience, Box 89, De Crespigny Park, London, SE5 8AF, UK
| |
Collapse
|
|
22
|
Repeated greater occipital nerve injections with corticosteroids in medically intractable chronic cluster headache: a retrospective study. Neurol Sci 2021; 43:1267-1272. [PMID: 34159486 PMCID: PMC8789713 DOI: 10.1007/s10072-021-05399-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 06/08/2021] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Current prophylactic drugs for cluster headache are associated with limited efficacy, serious side effects and poor tolerability. Greater occipital nerve injection (GON-injection) has been proven effective and safe as a single, one-time injection in episodic (ECH), and to a lesser extent, chronic cluster headache (CCH). We aim to analyse the effectiveness and safety of repeated GON-injections in medically intractable chronic cluster headache (MICCH). METHODS Clinical data of all cluster headache patients who had received at least one GON-injection between 2014 and 2018 in our tertiary headache centre were retrieved from patients' medical records. Clinical history was taken as part of routine care shortly before and 6 weeks after GON-injection. RESULTS We identified 47 MICCH patients (79 injections), and compared results with 22 non-MI CCH patients (30 injections) and 50 ECH patients (63 injections). Nineteen MICCH patients received repeated injections (32 in total, range 2-8). Rates of clinical relevant improvement to a first injection were similar in all groups (MICCH: 60%, non-MICCH 73%, ECH 76%; attack freedom: MICCH: 30%, non-MICCH 32%, ECH 43%). Furthermore, no difference in response to the first and second injection was shown between groups (all p > 0.29). Median effect duration in MICCH was 6 weeks (IQR 2.8-12 weeks). Side effects were only mild and local. CONCLUSION In this retrospective analysis, first and repeated GON-injections were well-tolerated and equally effective in MICCH as in non-MICCH, and ECH.
Collapse
|
|
23
|
Chowdhury D, Datta D, Mundra A. Role of Greater Occipital Nerve Block in Headache Disorders: A Narrative Review. Neurol India 2021; 69:S228-S256. [PMID: 34003170 DOI: 10.4103/0028-3886.315993] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background The proximity of sensory neurons in the upper cervical spinal cord to the trigeminal nucleus caudalis (TNC) neurons and the convergence of sensory input to TNC neurons from both cervical and trigeminal fibers underscore the rationale of using greater occipital nerve block (GON-block) for acute and preventive treatment in various headache disorders. Objective The aim of this study was to critically review the existing literature regarding the safety and efficacy of GON-block in various headache disorders. Methods We searched the eligible studies in English by searching in PubMed till December 31, 2020 for randomized controlled trials (RCTs), observational studies, open-label studies, case series, and case reports on the efficacy and the safety of GON-block for the treatment of headache disorders using the keywords "greater occipital nerve block", "headache" and "treatment". Studies using combination of GON-block and other peripheral nerve blocks (PNBs) and C2/C3 blocks were excluded. Results Seventy-two eligible studies were reviewed. Based on RCTs and open-label studies, good evidence of the efficacy of GON-block was found for migraine, cluster headache (CH), post-dural puncture headache (PDPH), cervicogenic headache (CGH), and occipital neuralgia (ON). The analgesic effect of GON-block outlasted its anesthetic effect by days to weeks. Evidence for acute and short-term (transitional) treatment was more robust than for long-term prevention. GON-block was found to be safe and the treatment-emergent adverse effects (TEAEs) were generally mild and transient. Conclusion GON-block is a useful modality of treatment in various headache disorders because of many attractive features such as its early effect in reducing the severity of pain, sustained effect following a single injection, easy technique, minimum invasiveness, minimum TEAE, no drug-to-drug interactions, and negligible cost.
Collapse
Affiliation(s)
- Debashish Chowdhury
- Department of Neurology, GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Debabrata Datta
- Department of Neurology, GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Ankit Mundra
- Department of Neurology, GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| |
Collapse
|
|
24
|
Lloyd J, Biloshytska M, Andreou AP, Lambru G. Noninvasive Neuromodulation in Headache: An Update. Neurol India 2021; 69:S183-S193. [PMID: 34003164 DOI: 10.4103/0028-3886.315998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Migraine is a common disabling primary headache condition. Although strives have been made in treatment, there remains an unmet need for safe, effective acute, and preventative treatments. The promising concept of neuromodulation of relevant neuronal targets in a noninvasive fashion for the treatment of primary headache disorders has led to the trial of numerous devices over the years. Objective We aimed to review the evidence on current neuromodulation treatments available for the management of primary headache disorders. Methods Randomized controlled trial as well as open-label and real-world studies on central and peripheral cephalic and noncephalic neuromodulation modalities in primary headaches were critically reviewed. Results The current evidence suggests a role of single-pulse transcranial magnetic stimulation, supraorbital nerve stimulation, and remote noncephalic electrical stimulation as migraine abortive treatments, with stronger evidence in episodic rather than in chronic migraine. Single-pulse transcranial magnetic stimulation and supraorbital nerve stimulation also hold promising evidence in episodic migraine prevention and initial positive evidence in chronic migraine prevention. More evidence should clarify the therapeutic role of the external vagus nerve stimulation and transcranial direct current stimulation in migraine. However, external vagus nerve stimulation may be effective in the acute treatment of episodic but not chronic cluster headache, in the prevention of hemicrania continua and paroxysmal hemicrania but not of short-lasting neuralgiform headache attacks. The difficulty in setting up sham-controlled studies has thus far prevented the publication of robust trials. This limitation along with the cost of these therapies has meant that their use is limited in most countries. Conclusion Neuromodulation is a promising nonpharmacological treatment approach for primary headaches. More studies with appropriate blinding strategies and reduction of device cost may allow more widespread approval of these treatments and in turn increase clinician's experience in neuromodulation.
Collapse
Affiliation(s)
- Joseph Lloyd
- Headache Research-Wolfson CARD, Institute of Psychology, Psychiatry and Neuroscience, King's College London, London, UK
| | - Maryna Biloshytska
- Headache Research-Wolfson CARD, Institute of Psychology, Psychiatry and Neuroscience, King's College London, London, UK
| | - Anna P Andreou
- Department of Functional Neurosurgery and Neuromodulation, Romodanov Neurosurgery Institute, National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine; The Headache Service, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Giorgio Lambru
- The Headache Service, Guy's and St Thomas' NHS Foundation Trust, London, UK
| |
Collapse
|
|
25
|
Cluster headache pathophysiology - insights from current and emerging treatments. Nat Rev Neurol 2021; 17:308-324. [PMID: 33782592 DOI: 10.1038/s41582-021-00477-w] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2021] [Indexed: 02/01/2023]
Abstract
Cluster headache is a debilitating primary headache disorder that affects approximately 0.1% of the population worldwide. Cluster headache attacks involve severe unilateral pain in the trigeminal distribution together with ipsilateral cranial autonomic features and a sense of agitation. Acute treatments are available and are effective in just over half of the patients. Until recently, preventive medications were borrowed from non-headache indications, so management of cluster headache is challenging. However, as our understanding of cluster headache pathophysiology has evolved on the basis of key bench and neuroimaging studies, crucial neuropeptides and brain structures have been identified as emerging treatment targets. In this Review, we provide an overview of what is known about the pathophysiology of cluster headache and discuss the existing treatment options and their mechanisms of action. Existing acute treatments include triptans and high-flow oxygen, interim treatment options include corticosteroids in oral form or for greater occipital nerve block, and preventive treatments include verapamil, lithium, melatonin and topiramate. We also consider emerging treatment options, including calcitonin gene-related peptide antibodies, non-invasive vagus nerve stimulation, sphenopalatine ganglion stimulation and somatostatin receptor agonists, discuss how evidence from trials of these emerging treatments provides insights into the pathophysiology of cluster headache and highlight areas for future research.
Collapse
|
|
26
|
Lambru G, Stubberud A, Rantell K, Lagrata S, Tronvik E, Matharu MS. Medical treatment of SUNCT and SUNA: a prospective open-label study including single-arm meta-analysis. J Neurol Neurosurg Psychiatry 2021; 92:233-241. [PMID: 33361408 PMCID: PMC7892380 DOI: 10.1136/jnnp-2020-323999] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 10/11/2020] [Accepted: 10/18/2020] [Indexed: 01/03/2023]
Abstract
INTRODUCTION The management of short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) remains challenging in view of the paucity of data and evidence-based treatment recommendations are missing. METHODS In this single-centre, non-randomised, prospective open-label study, we evaluated and compared the efficacy of oral and parenteral treatments for SUNCT and SUNA in a real-world setting. Additionally, single-arm meta-analyses of the available reports of SUNCT and SUNA treatments were conducted. RESULTS The study cohort comprised 161 patients. Most patients responded to lamotrigine (56%), followed by oxcarbazepine (46%), duloxetine (30%), carbamazepine (26%), topiramate (25%), pregabalin and gabapentin (10%). Mexiletine and lacosamide were effective in a meaningful proportion of patients but poorly tolerated. Intravenous lidocaine given for 7-10 days led to improvement in 90% of patients, whereas only 27% of patients responded to a greater occipital nerve block. No statistically significant differences in responders were observed between SUNCT and SUNA. In the meta-analysis of the pooled data, topiramate was found to be significantly more effective in SUNCT than SUNA patients. However, a higher proportion of SUNA than SUNCT was considered refractory to medications at the time of the topiramate trial, possibly explaining this isolated difference. CONCLUSIONS We propose a treatment algorithm for SUNCT and SUNA for clinical practice. The response to sodium channel blockers indicates a therapeutic overlap with trigeminal neuralgia, suggesting that sodium channels dysfunction may be a key pathophysiological hallmark in these disorders. Furthermore, the therapeutic similarities between SUNCT and SUNA further support the hypothesis that these conditions are variants of the same disorder.
Collapse
Affiliation(s)
- Giorgio Lambru
- Headache and Facial Pain Group, UCL Queen Square Institute of Neurology, London, UK
| | - Anker Stubberud
- Department of Neuromedicine and Movement Sciences, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Neurology, St. Olavs Hospital, Trondheim, Norway
| | - Khadija Rantell
- Education Unit, UCL Queen Square Institute of Neurology, London, UK
| | - Susie Lagrata
- Headache and Facial Pain Group, UCL Queen Square Institute of Neurology, London, UK.,Headache and Facial Pain Group, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Erling Tronvik
- Department of Neuromedicine and Movement Sciences, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Neurology, St. Olavs Hospital, Trondheim, Norway
| | - Manjit Singh Matharu
- Headache and Facial Pain Group, UCL Queen Square Institute of Neurology, London, UK .,Headache and Facial Pain Group, The National Hospital for Neurology and Neurosurgery, London, UK
| |
Collapse
|
|
27
|
Primaries non-migraine headaches treatment: a review. Neurol Sci 2020; 41:385-394. [PMID: 33021705 DOI: 10.1007/s10072-020-04762-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In the "headache world," great attention has always been paid to migraine patients, especially for the research and development of new therapies. For the other forms of primary headaches, especially those of Chapters 2 and 3 of the classification, there are however therapies that, even if not specific, can give significant results. Tension-type headache recognizes in NSAIDs the most effective drugs to treat acute attack, while prevention is based on the use of tricyclic antidepressants and muscle relaxants. For TACs, the discussion is more complex: first of all, there are two forms of primary headache that respond absolutely to indomethacin. For these, the main problem is how to manage the possible side effects arising from prolonged treatments and possibly what to use as an alternative. For cluster headaches and short-lasting unilateral neuralgiform headache attacks, we have drugs with good efficacy as regards medical therapy, such as verapamil or lamotrigine, but in recent years, neuromodulation techniques, both surgical and non-invasive, have also been affirming themselves, which represent a more possibility for forms of headache that are often very disabling and resistant to common analgesics.
Collapse
|
|
28
|
Chronic Cluster Headache Update and East-West Comparisons: Focusing on Clinical Features, Pathophysiology, and Management. Curr Pain Headache Rep 2020; 24:68. [PMID: 32990832 DOI: 10.1007/s11916-020-00902-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE OF REVIEW This review provides an update on chronic cluster headache (CH) focusing on clinical features, pathophysiology, and management as well as comparisons between Eastern and Western populations. RECENT FINDINGS Chronic CH in Eastern populations was relatively rare, compared to that in Western populations. Lacrimation and/or conjunctival injection is the most frequently reported cranial autonomic symptom, and visual aura is predominant in chronic CH patients. Neuroimaging evidence in both ethnic groups suggests that CH pathophysiology involves the hypothalamus and pain-modulatory areas, with dynamic alternations between CH episodes. Recent evidence indicates that midbrain dopaminergic systems may participate in CH chronicity. Noteworthy advances have emerged in neuromodulatory therapies for chronic CH, but treatment with calcitonin gene-related peptide (CGRP) monoclonal antibodies has been unsuccessful. Recent evidence shows divergence of chronic CH between Eastern and Western populations. Neuromodulatory therapies but not CGRP inhibition is effective in this intractable patient group.
Collapse
|
|
29
|
Ornello R, Lambru G, Caponnetto V, Frattale I, Di Felice C, Pistoia F, Sacco S. Efficacy and safety of greater occipital nerve block for the treatment of cluster headache: a systematic review and meta-analysis. Expert Rev Neurother 2020; 20:1157-1167. [PMID: 32781922 DOI: 10.1080/14737175.2020.1809379] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The treatment of cluster headache (CH) is challenging in view of the few evidence-based treatments. The authors aim to summarize the evidence of efficacy and safety of greater occipital nerve blocks (GONBs) in CH. AREAS COVERED The authors included papers indexed in PubMed and Web of Science from the beginning of indexing to 5 May 2020. They included both observational and randomized studies referring to patients with episodic and/or chronic CH. The authors identified 12 studies on 365 patients. Five studies (two randomized controlled trials) could be included in the meta-analyses. The pooled proportion of pain-free subjects at 1 month was 50% (95% CI 24-76%) with considerable heterogeneity (I2 = 88%; P < 0.01). The pooled relative risk ratio of pain freedom at 1 month in active versus control groups in the two included randomized controlled trials was 4.86 (95% CI, 1.35-17.55) without statistical heterogeneity (I2 = 0%; P = 0.39). Three studies showed decreased attack intensity, frequency, and duration after GONBs. The studies reported mild and transient adverse events. EXPERT OPINION Despite several limitations and considerable heterogeneity, the available data support the efficacy and safety of GONBs for the treatment of CH. Further large randomized trials are needed to confirm efficacy and establish optimal treatment protocols.
Collapse
Affiliation(s)
- Raffaele Ornello
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila , L'Aquila, Italy
| | - Giorgio Lambru
- Headache Centre, Guy and St Thomas' NHS Foundation Trust , London, UK
| | - Valeria Caponnetto
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila , L'Aquila, Italy
| | - Ilaria Frattale
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila , L'Aquila, Italy
| | - Chiara Di Felice
- Department of Internal Medicine, Public Health, Life and Environmental Sciences, University of L'Aquila , L'Aquila, Italy
| | - Francesca Pistoia
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila , L'Aquila, Italy
| | - Simona Sacco
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila , L'Aquila, Italy
| |
Collapse
|
|
30
|
García-Magro N, Negredo P, Martin YB, Nuñez Á, Avendaño C. Modulation of mechanosensory vibrissal responses in the trigeminocervical complex by stimulation of the greater occipital nerve in a rat model of trigeminal neuropathic pain. J Headache Pain 2020; 21:96. [PMID: 32762640 PMCID: PMC7410158 DOI: 10.1186/s10194-020-01161-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 07/17/2020] [Indexed: 12/19/2022] Open
Abstract
Background Stimulation of the occipital or trigeminal nerves has been successfully used to treat chronic refractory neurovascular headaches such as migraine or cluster headache, and painful neuropathies. Convergence of trigeminal and occipital sensory afferents in the ‘trigeminocervical complex’ (TCC) from cutaneous, muscular, dural, and visceral sources is a key mechanism for the input-induced central sensitization that may underlie the altered nociception. Both excitatory (glutamatergic) and inhibitory (GABAergic and glycinergic) mechanisms are involved in modulating nociception in the spinal and medullary dorsal horn neurons, but the mechanisms by which nerve stimulation effects occur are unclear. This study was aimed at investigating the acute effects of electrical stimulation of the greater occipital nerve (GON) on the responses of neurons in the TCC to the mechanical stimulation of the vibrissal pad. Methods Adult male Wistar rats were used. Neuronal recordings were obtained in laminae II-IV in the TCC in control, sham and infraorbital chronic constriction injury (CCI-IoN) animals. The GON was isolated and electrically stimulated. Responses to the stimulation of vibrissae by brief air pulses were analyzed before and after GON stimulation. In order to understand the role of the neurotransmitters involved, specific receptor blockers of NMDA (AP-5), GABAA (bicuculline, Bic) and Glycine (strychnine, Str) were applied locally. Results GON stimulation produced a facilitation of the response to light facial mechanical stimuli in controls, and an inhibition in CCI-IoN cases. AP-5 reduced responses to GON and vibrissal stimulation and blocked the facilitation of GON on vibrissal responses found in controls. The application of Bic or Str significantly reduced the facilitatory effect of GON stimulation on the response to vibrissal stimulation in controls. However, the opposite effect was found when GABAergic or Glycinergic transmission was prevented in CCI-IoN cases. Conclusions GON stimulation modulates the responses of TCC neurons to light mechanical input from the face in opposite directions in controls and under CCI-IoN. This modulation is mediated by GABAergic and Glycinergic mechanisms. These results will help to elucidate the neural mechanisms underlying the effectiveness of nerve stimulation in controlling painful craniofacial disorders, and may be instrumental in identifying new therapeutic targets for their prevention and treatment.
Collapse
Affiliation(s)
- Nuria García-Magro
- Department of Anatomy, Histology and Neuroscience, Medical School, Autonoma University of Madrid, c/ Arzobispo Morcillo 2, 28029, Madrid, Spain.,Programme in Neuroscience, Doctoral School, Autonoma University of Madrid, Madrid, Spain
| | - Pilar Negredo
- Department of Anatomy, Histology and Neuroscience, Medical School, Autonoma University of Madrid, c/ Arzobispo Morcillo 2, 28029, Madrid, Spain
| | - Yasmina B Martin
- Facultad de Medicina, Universidad Francisco de Vitoria, 28223, Madrid, Spain
| | - Ángel Nuñez
- Department of Anatomy, Histology and Neuroscience, Medical School, Autonoma University of Madrid, c/ Arzobispo Morcillo 2, 28029, Madrid, Spain
| | - Carlos Avendaño
- Department of Anatomy, Histology and Neuroscience, Medical School, Autonoma University of Madrid, c/ Arzobispo Morcillo 2, 28029, Madrid, Spain.
| |
Collapse
|
|
31
|
Abstract
INTRODUCTION The involvement of the calcitonin gene-related peptide (CGRP) pathway in primary headache disorders, especially migraine, had led to recent success in the development of new migraine therapies. The CGRP pathway also plays a role in the pathophysiology of cluster headache, so CGRP pathway monoclonal antibodies have been studied in the prevention of cluster headache attacks. AREAS COVERED This review will outline the trials of fremanezumab and galcanezumab, the two CGRP pathway monoclonal antibodies that have undergone trials in cluster headache prevention. This review will highlight key efficacy and safety outcomes from the trials. EXPERT OPINION Galcanezumab was shown to be efficacious, reducing the frequency of attacks in episodic cluster headache, while fremanezumab failed its primary endpoint in episodic cluster headache. Both fremanezumab and galcanezumab trials in chronic cluster headache were terminated after futility analysis predicting the failure of both trials to fulfil their primary endpoint. The role of CGRP in cluster headache supports ongoing trials of the remaining CGRP pathway monoclonal antibodies and gepants for preventive and acute treatment. A broad view would include targeting neuropeptides involved in parasympathetic signaling in cluster headache, such as pituitary adenylate cyclase-activating peptide (PACAP); such targets warrant exploration in the search of new treatments.
Collapse
Affiliation(s)
- Calvin Chan
- Headache Group, Department of Basic and Clinical Neuroscience, Institute of Psychology, Psychiatry and Neuroscience, King's College London
| | - Peter J Goadsby
- NIHR-Wellcome Trust King's Clinical Research Facility, SLaM Biomedical Research Centre, King's College Hospital , London, UK
| |
Collapse
|
|
32
|
Ornello R, Palmisani S, Murphy M, Sacco S, Al-Kaisy A, Lambru G. Sphenopalatine Ganglion Pulsed Radiofrequency for the Treatment of Refractory Chronic SUNCT and SUNA: A Prospective Case Series. Headache 2020; 60:938-945. [PMID: 32202666 DOI: 10.1111/head.13788] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 02/13/2020] [Accepted: 02/14/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVES We aimed to evaluate the safety and effectiveness of sphenopalatine ganglion pulsed radiofrequency (SPG-PRF) for the treatment of patients with refractory chronic short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and with cranial autonomic symptoms (SUNA). BACKGROUND SPG-PRF is a minimally invasive, non-neurodestructive procedure already tested in refractory chronic cluster headache with mixed outcomes. However, no data have been produced in SUNCT/SUNA. METHODS This was a prospective clinical audit of outcomes. Consecutive patients with chronic SUNCT/SUNA refractory to medical treatments and treated with SPG-PRF, were included in the analysis. The SPG-PRF was performed percutaneously via a lateral, infra-zygomatic approach. Responders were defined as patients with a reduction in number and/or severity of headache episodes by ≥30% for ≥3 months. Responders to the first procedure were offered to have the treatment repeated. RESULTS Nine patients (6 female) were analyzed. After a median follow-up of 30 months (range 2-30), 7 patients were considered responders to the treatment (77.8%) for a median of 6 months (range: 4-10), 1 patient obtained 40% improvement for 2 months, and 1 patient did experience any improvement. No procedure-related immediate or delayed side effects were reported. Three patients (33.3%) experienced a worsening of the head pain for 2-4 weeks immediately after the procedure. Four responders had SPG-PRF repeated; a reproducible response was obtained in two of them. CONCLUSIONS In our small series of patients with refractory chronic SUNCT/SUNA, SPG-PRF was a safe and effective treatment modality. The potential reproducible positive effect of subsequent treatments may prevent or delay the use of more invasive and costly interventions for at least a proportion of these patients.
Collapse
Affiliation(s)
- Raffaele Ornello
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Stefano Palmisani
- The Pain Management and Neuromodulation Centre, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Madeleine Murphy
- The Headache Service, Pain Management and Neuromodulation Centre, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Simona Sacco
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Adnan Al-Kaisy
- The Pain Management and Neuromodulation Centre, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Giorgio Lambru
- The Headache Service, Pain Management and Neuromodulation Centre, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| |
Collapse
|
|
33
|
Abstract
Cluster headache is characterised by attacks of excruciating unilateral headache or facial pain lasting 15 min to 3 h and is seen as one of the most intense forms of pain. Cluster headache attacks are accompanied by ipsilateral autonomic symptoms such as ptosis, miosis, redness or flushing of the face, nasal congestion, rhinorrhoea, peri-orbital swelling and/or restlessness or agitation. Cluster headache treatment entails fast-acting abortive treatment, transitional treatment and preventive treatment. The primary goal of prophylactic and transitional treatment is to achieve attack freedom, although this is not always possible. Subcutaneous sumatriptan and high-flow oxygen are the most proven abortive treatments for cluster headache attacks, but other treatment options such as intranasal triptans may be effective. Verapamil and lithium are the preventive drugs of first choice and the most widely used in first-line preventive treatment. Given its possible cardiac side effects, electrocardiogram (ECG) is recommended before treating with verapamil. Liver and kidney functioning should be evaluated before and during treatment with lithium. If verapamil and lithium are ineffective, contraindicated or discontinued because of side effects, the second choice is topiramate. If all these drugs fail, other options with lower levels of evidence are available (e.g. melatonin, clomiphene, dihydroergotamine, pizotifen). However, since the evidence level is low, we also recommend considering one of several neuromodulatory options in patients with refractory chronic cluster headache. A new addition to the preventive treatment options in episodic cluster headache is galcanezumab, although the long-term effects remain unknown. Since effective preventive treatment can take several weeks to titrate, transitional treatment can be of great importance in the treatment of cluster headache. At present, greater occipital nerve injection is the most proven transitional treatment. Other options are high-dose prednisone or frovatriptan.
Collapse
|
|
34
|
Wei DY, Khalil M, Goadsby PJ. Managing cluster headache. Pract Neurol 2019; 19:521-528. [PMID: 31278205 PMCID: PMC6902063 DOI: 10.1136/practneurol-2018-002124] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 01/10/2019] [Accepted: 03/18/2019] [Indexed: 11/04/2022]
Abstract
Cluster headache is a neurological disorder that presents with unilateral severe headache associated with ipsilateral cranial autonomic symptoms. Cluster headache attacks often occur more than once a day, and typically manifesting in bouts. It has a point prevalence of 1 in 1000 and is the most common trigeminal autonomic cephalalgia. This article aims to guide general neurologists to an accurate diagnosis and practical management options for cluster headache patients.
Collapse
Affiliation(s)
- Diana Y Wei
- Headache Group, Department of Basic and Clinical Neuroscience, King's College London, London, UK
| | - Modar Khalil
- Headache Group, Department of Basic and Clinical Neuroscience, King's College London, London, UK
- Department of Neurology, Hull Royal Infirmary, Hull, UK
| | - Peter J Goadsby
- Headache Group, Department of Basic and Clinical Neuroscience, King's College London, London, UK
- NIHR-Wellcome Trust King's Clinical Research Facility, SLaM Biomedical Research Centre, King's College Hospital, London, UK
| |
Collapse
|
|
35
|
Weatherall MW, Nandi D. Percutaneous electrical nerve stimulation (PENS) therapy for refractory primary headache disorders: a pilot study. Br J Neurosurg 2019; 33:608-612. [DOI: 10.1080/02688697.2019.1671951] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
| | - Dipankar Nandi
- Department of Neurosurgery, Charing Cross Hospital, Imperial College NHS Healthcare, London, UK
| |
Collapse
|
|
36
|
The Greater Occipital Nerve and Obliquus Capitis Inferior Muscle: Anatomical Interactions and Implications for Occipital Pain Syndromes. Plast Reconstr Surg 2019; 144:730-736. [PMID: 31461039 DOI: 10.1097/prs.0000000000005945] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND The compression/injury of the greater occipital nerve has been identified as a trigger of occipital headaches. Several compression points have been described, but the morphology of the myofascial unit between the greater occipital nerve and the obliquus capitis inferior muscle has not been studied yet. METHODS Twenty fresh cadaveric heads were dissected, and the greater occipital nerve was tracked from its emergence to its passage around the obliquus capitis inferior. The intersection point between the greater occipital nerve and the obliquus capitis inferior, and the length and thickness of the obliquus capitis inferior, were measured. In addition, the nature of the interaction and whether the nerve passed through the muscle were also noted. RESULTS All nerves passed either around the muscle loosely (type I), incorporated in the dense superficial muscle fascia (type II), or directly through a myofascial sleeve within the muscle (type III). The obliquus capitis inferior length was 5.60 ± 0.46 cm. The intersection point between the obliquus capitis inferior and the greater occipital nerve was 6.80 ± 0.68 cm caudal to the occiput and 3.56 ± 0.36 cm lateral to the midline. The thickness of the muscle at its intersection with the greater occipital nerve was 1.20 ± 0.25 cm. Loose, tight, and intramuscular connections were found in seven, 31, and two specimens, respectively. CONCLUSIONS The obliquus capitis inferior remains relatively immobile during traumatic events, like whiplash injuries, placing strain as a tethering point on the greater occipital nerve. Better understanding of the anatomical relationship between the greater occipital nerve and the obliquus capitis inferior can be clinically useful in cases of posttraumatic occipital headaches for diagnostic and operative planning purposes.
Collapse
|
|
37
|
Suboccipital steroid injection alone as a preventive treatment for cluster headache. J Clin Neurosci 2019; 68:140-145. [PMID: 31326284 DOI: 10.1016/j.jocn.2019.07.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 07/05/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Suboccipital steroid injection can be used as a preventive treatment for episodic and chronic cluster headache (CH). In recent studies, prophylactic treatment has been used in addition to suboccipital steroid injection. In this study, we aimed to investigate the effectivity of the sole use of rapid- and long-acting steroid injections without prophylactic treatment in patients with episodic and chronic CH. METHODS The retrospective study included 51 patients with episodic and chronic CH that underwent greater occipital nerve (GON) blockade with a single dose of rapid- and long-acting steroid injection without additional prophylactic treatment. The frequency, severity, and duration of attacks after GON blockade as well as the side effects and long-term outcomes were reviewed. RESULTS In 28 (54.9%) patients, no attack occurred after GON blockade and cluster bouts were aborted. Mean duration of attacks was 86.67 ± 37.45 min before the treatment. However, in the 23 patients that had at least one attack after GON blockade, the mean duration of attacks was 31.73 ± 36.10 min between post-treatment days 0-3, 29.35 ± 40.49 min between post-treatment days 4-10, 28.48 ± 42.17 min between post-treatment days 11-28, and 35.65 ± 46.55 min after the post-treatment day 28 (p < 0.001). Moreover, 10 (37.04%) out of 27 patients with episodic CH who periodically had one or two cluster bouts in a year had no CH attack at the time of the expected subsequent cluster bout. CONCLUSION GON blockade is a practical, reliable, and cost-effective treatment option for patients with episodic and chronic CH. Moreover, GON blockade is highly effective in reducing headache attacks and even aborting cluster bouts in CH patients without requiring additional prophylactic treatment.
Collapse
|
|
38
|
Asioli GM, Merli E, Favoni V, Sartori A, Pierangeli G, Cevoli S. Greater Occipital Nerve Infiltration During Pregnancy in Cluster Headache: A Case Report. Headache 2019; 59:930-932. [DOI: 10.1111/head.13553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Gian Maria Asioli
- Department of Biomedical and Neuromotor Sciences University of Bologna Bologna Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna Bologna Italy
| | - Elena Merli
- Department of Biomedical and Neuromotor Sciences University of Bologna Bologna Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna Bologna Italy
| | - Valentina Favoni
- Department of Biomedical and Neuromotor Sciences University of Bologna Bologna Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna Bologna Italy
| | - Alex Sartori
- Department of Biomedical and Neuromotor Sciences University of Bologna Bologna Italy
| | - Giulia Pierangeli
- Department of Biomedical and Neuromotor Sciences University of Bologna Bologna Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna Bologna Italy
| | - Sabina Cevoli
- IRCCS Istituto delle Scienze Neurologiche di Bologna Bologna Italy
| |
Collapse
|
|
39
|
Miller S, Lagrata S, Matharu M. Multiple cranial nerve blocks for the transitional treatment of chronic headaches. Cephalalgia 2019; 39:1488-1499. [DOI: 10.1177/0333102419848121] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background Multiple cranial nerve blocks of the greater and lesser occipital, supraorbital, supratrochlear and auriculotemporal nerves are widely used in the treatment of primary headaches. We present efficacy and safety data for these procedures. Methods In an uncontrolled open-label prospective study, 119 patients with chronic cluster headache, chronic migraine, short lasting unilateral neuralgiform attack disorders, new daily persistent headaches, hemicrania continua and chronic paroxysmal hemicrania were examined. All had failed to respond to greater occipital nerve blocks. Response was defined as a 50% reduction in either daily attack frequency or moderate-to-severe headache days after 2 weeks. Results The response rate of the whole cohort was 55.4%: Chronic cluster headache, 69.2%; chronic migraine, 49.0%; short lasting unilateral neuralgiform attack disorders, 56.3%; new daily persistent headache, 10.0%; hemicrania continua, 83.3%; and chronic paroxysmal hemicrania, 25.0%. Time to benefit was between 0.50 and 33.58 hours. Benefit was maintained for up to 4 weeks in over half of responders in all groups except chronic migraine and paroxysmal hemicrania. Only minor adverse events were recorded. Conclusion Multiple cranial nerve blocks may provide an efficacious, well tolerated and reproducible transitional treatment for chronic headache disorders when greater occipital nerve blocks have been unsuccessful.
Collapse
Affiliation(s)
- Sarah Miller
- Headache Group, Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Susie Lagrata
- Headache Group, Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Manjit Matharu
- Headache Group, Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| |
Collapse
|
|
40
|
Tajti J, Szok D, Nyári A, Vécsei L. Therapeutic strategies that act on the peripheral nervous system in primary headache disorders. Expert Rev Neurother 2019; 19:509-533. [DOI: 10.1080/14737175.2019.1615447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- János Tajti
- Department of Neurology, Faculty of Medicine, Interdisciplinary Excellence Centre, University of Szeged, Szeged, Hungary
| | - Délia Szok
- Department of Neurology, Faculty of Medicine, Interdisciplinary Excellence Centre, University of Szeged, Szeged, Hungary
| | - Aliz Nyári
- Department of Neurology, Faculty of Medicine, Interdisciplinary Excellence Centre, University of Szeged, Szeged, Hungary
| | - László Vécsei
- Department of Neurology, Faculty of Medicine, Interdisciplinary Excellence Centre, University of Szeged, Szeged, Hungary
- MTA-SZTE Neuroscience Research Group of the Hungarian Academy of Sciences, Szeged, Hungary
| |
Collapse
|
|
41
|
Liu SC, Kao MC, Huang YC, Su WF. Vidian Neurectomy for Management of Chronic Cluster Headache. Neurosurgery 2019; 84:1059-1064. [PMID: 30535031 DOI: 10.1093/neuros/nyy136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 03/19/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Management of chronic cluster headache (CCH) remains a challenging endeavor, and the optimal surgical approach for medically refractory CCH remains controversial. OBJECTIVE To conduct a preliminary evaluation of the efficacy and safety of vidian neurectomy (VN) in patients with medically refractory CCH. METHODS Between March 2013 and December 2015, 9 CCH patients, all of whom had failed to respond to conservative therapy, underwent VN with a precise nerve cut and maximal preservation of the sphenopalatine ganglion. Data included demographic variables, cluster headache onset and duration, mean attack frequency, mean attack intensity, and pain disability index measures pre- and through 12-mo postsurgery. RESULTS Seven of the 9 cases (77.8%) showed immediate improvement. Improvement was delayed by 1 mo in 1 patient, after which the surgical effects of pain relief were maintained throughout the follow-up period. One patient (11.1%) did not improve after surgery. One year after VN, patients' mean attack frequency, mean attack intensity, and pain disability index decreased by 54.5%, 52.9%, and 56.4%, respectively. No patient experienced treatment-related side effects or complications. CONCLUSION VN is an effective treatment method for CCH patients. Precise Vidian nerve identification and maximal preservation of the sphenopalatine ganglion may achieve good surgical outcomes and dramatically improve quality of life among patients, without significant adverse events.
Collapse
Affiliation(s)
- Shao-Cheng Liu
- Department of Otolaryngology-Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Ming-Chang Kao
- Division of Pain Medicine, Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan, Republic of China.,School of Medicine, Tzu Chi University, Hualien, Taiwan, Republic of China
| | - Yun-Chen Huang
- School of Medicine, Tzu Chi University, Hualien, Taiwan, Republic of China.,Department of Otolaryngology-Head and Neck Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan, Republic of China
| | - Wan-Fu Su
- School of Medicine, Tzu Chi University, Hualien, Taiwan, Republic of China.,Department of Otolaryngology-Head and Neck Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan, Republic of China
| |
Collapse
|
|
42
|
Silek H. Combination of transcutaneous electrical nerve stimulation (tens) and occipital nerve block in refractory cluster headache. SANAMED 2019. [DOI: 10.24125/sanamed.v14i3.356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Cluster headache (CH) can be extremely resistant to medical treatment. There are no prognostic signs that can previously determent persistence and resistance to medical treatment. We report on medical treatment-resistant cluster headache that relieved with transcutaneous electric nerve stimulation treatment followed with occipital nerve block (ONB) method. A 39-year-old male patient that was diagnosed with a cluster headache that was resistant to a combination of the highest tolerated drug dose of verapamil, valproic acid, and oral methylprednisolone. Due to its resistance to medical treatment for one month, in addition, treatment with transcutaneous electric nerve stimulation and following (ONB) showed sudden and permanent control of headache.
Collapse
|
|
43
|
García-Magro N, Martin YB, Negredo P, Avendaño C. The greater occipital nerve and its spinal and brainstem afferent projections: A stereological and tract-tracing study in the rat. J Comp Neurol 2018; 526:3000-3019. [PMID: 30080243 DOI: 10.1002/cne.24511] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 07/27/2018] [Accepted: 08/02/2018] [Indexed: 12/27/2022]
Abstract
The neuromodulation of the greater occipital nerve (GON) has proved effective to treat chronic refractory neurovascular headaches, in particular migraine and cluster headache. Moreover, animal studies have shown convergence of cervical and trigeminal afferents on the same territories of the upper cervical and lower medullary dorsal horn (DH), the so-called trigeminocervical complex (TCC), and recent studies in rat models of migraine and craniofacial neuropathy have shown that GON block or stimulation alter nociceptive processing in TCC. The present study examines in detail the anatomy of GON and its central projections in the rat applying different tracers to the nerve and quantifying its ultrastructure, the ganglion neurons subserving GON, and their innervation territories in the spinal cord and brainstem. With considerable intersubject variability in size, GON contains on average 900 myelinated and 3,300 unmyelinated axons, more than 90% of which emerge from C2 ganglion neurons. Unmyelinated afferents from GON innervates exclusively laminae I-II of the lateral DH, mostly extending along segments C2-3 . Myelinated fibers distribute mainly in laminae I and III-V of the lateral DH between C1 and C6 and, with different terminal patterns, in medial parts of the DH at upper cervical segments, and ventrolateral rostral cuneate, paratrigeminal, and marginal part of the spinal caudal and interpolar nuclei. Sparse projections also appear in other locations nearby. These findings will help to better understand the bases of sensory convergence on spinomedullary systems, a critical pathophysiological factor for pain referral and spread in severe painful craniofacial disorders.
Collapse
Affiliation(s)
- Nuria García-Magro
- Autonoma University of Madrid, Medical School, Department of Anatomy, Histology & Neuroscience, Madrid, Spain
| | - Yasmina B Martin
- Francisco de Vitoria University (UFV), Department of Anatomy, Faculty of Health Sciences, Madrid, Spain
| | - Pilar Negredo
- Autonoma University of Madrid, Medical School, Department of Anatomy, Histology & Neuroscience, Madrid, Spain
| | - Carlos Avendaño
- Autonoma University of Madrid, Medical School, Department of Anatomy, Histology & Neuroscience, Madrid, Spain
| |
Collapse
|
|
44
|
Wu M, Hu T, Wu R. [Dissection and observation of a large unnamed nerve in the posterior cervical triangle]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2018; 38:1261-1265. [PMID: 30377120 DOI: 10.3969/j.issn.1673-4254.2018.10.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To characterize the anatomical features of a large unnamed nerve in the posterior cervical triangle and clarify its relationship with the lesser occipital nerve. METHODS We dissected 31 adult formalin-fixed cadaver head and neck specimens (62 sides). The lateral cervical region, the anterior cervical region, the sternocleidomastoid region, and the occipital region were dissected to define the anatomical features of the unnamed nerve. RESULTS This unnamed nerve was identified in the posterior cervical triangle in 96.8% of the specimens. The main trunk of the nerve had a diameter of about 3 mm with a length of around 10 cm. The nerve arose from the anterior branch of the second cervical nerve (C2, C2-3), entered the posterior cervical triangle at 1-3 cm above the accessory nerve, and continued to ascend along or in parallel with the posterior border of the sternocleidomastoid muscle. It passed between the attachments of the sternocleidomastoid and the trapezius to the occiput and divided into 3-5 branches, which innervated the skin area between the lesser and greater occipital nerves. CONCLUSIONS We identified a large unnamed nerve in the posterior cervical triangle, for which we coined the name "long occipital nerve" based on its unique anatomical features. The discovery of this nerve can be important for local surgery and for diagnosis and treatment of related diseases.
Collapse
Affiliation(s)
- Min Wu
- Department of Histology and Embryology, Wannan Medical College, Wuhu 241002, China
| | - Tianhan Hu
- Experimental Training Center for Medical Information, Wannan Medical College, Wuhu 241002, China
| | - Rangrang Wu
- Department of Anatomy, Wannan Medical College, Wuhu 241002, China
| |
Collapse
|
|
45
|
Berk T, Ashina S, Martin V, Newman L, Vij B. Diagnosis and Treatment of Primary Headache Disorders in Older Adults. J Am Geriatr Soc 2018; 66:2408-2416. [PMID: 30251385 DOI: 10.1111/jgs.15586] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 07/17/2018] [Accepted: 07/24/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To provide a unique perspective on geriatric headache and a number of novel treatment options that are not well known outside of the headache literature. DESIGN Review of the most current and relevant headache literature for practitioners specializing in geriatric care. RESULTS Evaluation and management of headache disorders in older adults requires an understanding of the underlying pathophysiology and how it relates to age-related physiological changes. To treat headache disorders in general, the appropriate diagnosis must first be established, and treatment of headaches in elderly adults poses unique challenges, including potential polypharmacy, medical comorbidities, and physiological changes associated with aging. CONCLUSION The purpose of this review is to provide a guide to and perspective on the challenges inherent in treating headaches in older adults. J Am Geriatr Soc 66:2408-2416, 2018.
Collapse
Affiliation(s)
- Thomas Berk
- Division of Headache, Department of Neurology, School of Medicine, New York University, New York, New York
| | - Sait Ashina
- Division of Headache, Department of Neurology, School of Medicine, New York University, New York, New York
| | - Vincent Martin
- Headache and Facial Pain Center, Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Lawrence Newman
- Division of Headache, Department of Neurology, School of Medicine, New York University, New York, New York
| | - Brinder Vij
- Headache and Facial Pain Center, Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| |
Collapse
|
|
46
|
Abstract
Background Occipital neuralgia is an uncommon disorder characterized by severe pain involving the posterior scalp in the distribution of the greater and lesser occipital nerves. In cases refractory to pharmacotherapy, invasive treatment options may be warranted. The aim of the present study was to examine the effects of thermal radiofrequency ablation (TRF) on occipital neuralgia. We hypothesized that this procedure would result in long-term pain relief. Methods All patients who underwent TRF of the greater and lesser occipital nerves between January 1, 2013 and March 23, 2016 were identified. Medical records were reviewed for preprocedure pain score, 1-month postprocedure pain score, patient-defined percent pain relief according to the visual analog scale (on which zero equals no pain and 10 represents the worst pain imaginable), and length of pain relief. The primary outcomes were the differences between preprocedure and 1-month postprocedure pain scores (mean change from baseline), percent pain relief, and patient-reported length of relief. Results A total of 50 patients were identified; 4 patients were excluded because of insufficient data as a result of loss to follow-up. A significant difference was found between preprocedure and postprocedure patient-reported pain scores (6.7 vs 2.7, respectively; P < 0.001), equating to a mean reduction in pain scores 1-month postprocedure of 4.0 ± 3.3. The mean patient-defined percent pain relief was 76.3% ± 25.0%. The mean patient-reported length of relief was 6.5 ± 5.1 months. Conclusion This study suggests that TRF may reduce pain scores for approximately 6 months.
Collapse
|
|
47
|
Rozen TD. High-Volume Anesthetic Suboccipital Nerve Blocks for Treatment Refractory Chronic Cluster Headache With Long-Term Efficacy Data: An Observational Case Series Study. Headache 2018; 59:56-62. [DOI: 10.1111/head.13394] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2018] [Indexed: 11/26/2022]
|
|
48
|
Abstract
Cluster headache is a severe headache disorder with considerable impact on quality of life. The pathophysiology of the disease remains poorly understood. With few specific targets for treatment, current guidelines mainly include off-label treatment with medication. However, new targets for possible treatment options are emerging. Calcitonin gene-related peptide (CGRP)-targeted medication could become the first (cluster) headache-specific treatment option. Other exciting new treatment options include invasive and non-invasive neuromodulation techniques. Here, we provide a short overview of new targets and treatment options that are being investigated for cluster headache.
Collapse
Affiliation(s)
- Patty Doesborg
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Joost Haan
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands.,Department of Neurology, Alrijne Ziekenhuis, Leiderdorp, Netherlands
| |
Collapse
|
|
49
|
Abstract
Trigeminal autonomic cephalalgia (TAC) encompasses 4 unique primary headache types: cluster headache, paroxysmal hemicrania, hemicrania continua, and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms. They are grouped on the basis of their shared clinical features of unilateral headache of varying durations and ipsilateral cranial autonomic symptoms. The shared clinical features reflect the underlying activation of the trigeminal-autonomic reflex. The treatment for TACs has been limited and not specific to the underlying pathogenesis. There is a proportion of patients who are refractory or intolerant to the current standard medical treatment. From instrumental bench work research and neuroimaging studies, there are new therapeutic targets identified in TACs. Treatment has become more targeted and aimed towards the pathogenesis of the conditions. The therapeutic targets range from the macroscopic and structural level down to the molecular and receptor level. The structural targets for surgical and noninvasive neuromodulation include central neuromodulation targets: posterior hypothalamus and, high cervical nerves, and peripheral neuromodulation targets: occipital nerves, sphenopalatine ganglion, and vagus nerve. In this review, we will also discuss the neuropeptide and molecular targets, in particular, calcitonin gene-related peptide, somatostatin, transient receptor potential vanilloid-1 receptor, nitric oxide, melatonin, orexin, pituitary adenylate cyclase-activating polypeptide, and glutamate.
Collapse
Affiliation(s)
- Diana Y Wei
- Headache Group, Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - Rigmor H Jensen
- Danish Headache Centre, Department of Neurology, Rigshospitalet-Glostrup, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
|
50
|
Miller S, Watkins L, Matharu M. Predictors of response to occipital nerve stimulation in refractory chronic headache. Cephalalgia 2017; 38:1267-1275. [DOI: 10.1177/0333102417728747] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Occipital nerve stimulation is a promising treatment for refractory chronic headache disorders, but is invasive and costly. Identifying predictors of response would be useful in selecting patients. We present the results of an open-label prospective cohort study of 100 patients (35 chronic migraine, 33 chronic cluster headache, 20 short-lasting unilateral neuralgiform headache attacks and 12 hemicrania continua) undergoing occipital nerve stimulation, using a multivariate binary regression analysis to identify predictors of response. Results Response rate of the cohort was 48%. Multivariate analysis showed short lasting unilateral neuralgiform headache attacks (OR 6.71; 95% CI 1.49–30.05; p = 0.013) and prior response to greater occipital nerve block (OR 4.22; 95% CI 1.35–13.21; p = 0.013) were associated with increased likelihood of response. Presence of occipital pain (OR 0.27; 95% CI 0.09–0.76; p = 0.014) and the presence of severe anxiety and/or depression (as measured on hospital anxiety and depression score) at time of implantation (OR 0.32; 95% CI 0.11–0.91; p = 0.032) were associated with reduced likelihood of response. Conclusion Possible clinical predictors of response to occipital nerve stimulation for refractory chronic headaches have been identified. Our data shows that those with short-lasting unilateral neuralgiform headache attacks respond better than those with chronic migraine, and that a prior response to greater occipital nerve block is associated with positive outcomes. This study suggests that the presence of occipital pain and severe mood disorder at time of implant are both associated with poor outcomes to occipital nerve stimulation.
Collapse
Affiliation(s)
- Sarah Miller
- Headache Group The National Hospital for Neurology and Neurosurgery, London, UK
- Institute of Neurology, University College London, UK
| | - Laurence Watkins
- Institute of Neurology, University College London, UK
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Manjit Matharu
- Headache Group The National Hospital for Neurology and Neurosurgery, London, UK
- Institute of Neurology, University College London, UK
| |
Collapse
|