Non-hypothalamic cluster headache: the role of the greater occipital nerve in cluster headache pathogenesis

A Rare Case of Cluster Headache Occurring Exclusively During Sleep Without Autonomic Symptoms and Agitation: A Case Report and Literature Review

As a primary headache disorder, cluster headache (CH) is a severe unilateral headache that recurs at certain times of the year, such as during season changes. It is characterized by autonomic symptoms, such as ipsilateral lacrimal and nasal discharge, as well as an inability to stay still during headache attacks. We report a rare case of CH in a 67-year-old male who presented with a severe right-sided headache lasting 30 minutes to one hour and occurring only during sleep. The headache resolved within five minutes after the subcutaneous injection of sumatriptan and was not accompanied by any autonomic symptoms or clear agitation.

[Ultrasound in interventional pain therapy]

Peripheral nerve blocks are currently performed relatively blind even in the most complex anatomical structures and physicians mostly rely on palpable anatomical landmarks on the surface. Ultrasound has become an indispensable part of the modern medical world and has long since found its way into almost all medical professions. More and more this trend also reaches interventional pain physicians as it is possible to accurately target structures, to track the needle course during the intervention and to visualize the spread of the local anesthetic. Another advantage compared to other radiological techniques is the profound radiation safety for patients as well as for personnel performing the intervention. A deep understanding of anatomy and its correlate in ultrasound images is one of the most important requirements for the successful use of these interventional techniques. Moreover, the safe performance of the procedure depends on the simultaneous hand-eye coordination. Nevertheless, despite the euphoria ultrasound technology should only be used in pain management with sufficient indications.

Neurostimulation in cluster headache: A review of current progress

Purpose of review

Neurostimulation has emerged as a viable treatment for intractable chronic cluster headache. Several therapeutic strategies are being investigated including stimulation of the hypothalamus, occipital nerves and sphenopalatine ganglion. The aim of this review is to provide an overview of the rationale, methods and progress for each of these.

Latest findings

Results from a randomized, controlled trial investigating sphenopalatine ganglion stimulation have just been published. Reportedly the surgery is relatively simple and it is apparently the only therapy that provides relief acutely.

Summary

The rationale behind these therapies is based on growing evidence from clinical, hormonal and neuroimaging studies. The overall results are encouraging, but unfortunately not all patients have benefited. All the mentioned therapies require weeks to months of stimulation for a prophylactic effect to occur, suggesting brain plasticity as a possible mechanism, and only stimulation of the sphenopalatine ganglion has demonstrated an acute, abortive effect. Predictors of effect for all modes of neurostimulation still need to be identified and in the future, the least invasive and most effective strategy must be preferred as first-line therapy for intractable chronic cluster headache.

[Ultrasound in interventional pain therapy]

Peripheral nerve blocks are currently performed relatively blind even in the most complex anatomical structures and physicians mostly rely on palpable anatomical landmarks on the surface. Ultrasound has become an indispensable part of the modern medical world and has long since found its way into almost all medical professions. More and more this trend also reaches interventional pain physicians as it is possible to accurately target structures, to track the needle course during the intervention and to visualize the spread of the local anesthetic. Another advantage compared to other radiological techniques is the profound radiation safety for patients as well as for personnel performing the intervention. A deep understanding of anatomy and its correlate in ultrasound images is one of the most important requirements for the successful use of these interventional techniques. Moreover, the safe performance of the procedure depends on the simultaneous hand-eye coordination. Nevertheless, despite the euphoria ultrasound technology should only be used in pain management with sufficient indications.

Positional cluster-like headache. A case report of a neurovascular compression between the third cervical root and the vertebral artery

Symptomatic cluster-like headaches have been described with lesions of the trigeminal and parasympathetic systems. Here, we report the case of a 44-year-old woman with continuous auricular pain and a positional cluster-like headache associated with red ear syndrome. Clinical data and morphological investigations raised the hypothesis of a neurovascular compression between the C3 root and vertebral artery. Neurosurgical exploration found a fibrosis surrounding both the C3 root and the vertebral artery. The excellent outcome after microvascular cervical decompression suggests a causal relationship between the cluster-like headache and the vertebral constraint on the C3 root.

CYBERKNIFE TARGETING THE PTERYGOPALATINE GANGLION FOR THE TREATMENT OF CHRONIC CLUSTER HEADACHES

OBJECTIVE

Cluster headache (CH) is a severe unilateral and periorbital facial pain syndrome that is often associated with autonomic symptoms, including ipsilateral lacrimation, nasal congestion, conjunctival injection, miosis, ptosis, and eyelid edema. We evaluated the treatment of medically refractory CH with CyberKnife (Accuray, Inc., Sunnyvale, CA) stereotactic radiosurgery targeting the pterygopalatine ganglion.

CLINICAL PRESENTATION

A 56-year-old man presented with a 20-year history of medically refractory CH. His symptoms were described as left-sided, severe, stabbing, burning, and often being associated with tearing and rhinorrhea. These headaches occurred virtually every morning and interfered with sleep, lifestyle, and work performance.

INTERVENTION

The patient underwent two pterygopalatine nerve block trials, both of which resulted in the complete relief of headaches for a 24-hour period. Contrast-enhanced computed axial tomography and magnetic resonance imaging scans were fused for target identification and treatment planning. The target volume measured 0.296 cm3 and a single fraction of 45.50 Gy was delivered to the 78% isodose line with a maximum dose of 65 Gy. The patient kept a detailed diary of his headaches and was followed for 12 months after treatment.

CONCLUSION

Results of CyberKnife targeting of the pterygopalatine ganglion in a patient with medically intractable CHs have revealed a significant decrease in the severity and frequency of headaches after a 12-month follow-up period. In addition, the patient has been able to reduce his medication intake, allowing for a significant decrease in medication-related side effects. Longer follow-up periods and additional studies are required to determine the long-term efficacy and late side effects of this treatment strategy.