Percutaneous retrogasserian glycerol rhizolysis for treatment of chronic intractable cluster headaches: long-term results

European Academy of Neurology guidelines on the treatment of cluster headache

BACKGROUND AND PURPOSE

Cluster headache is a relatively rare, disabling primary headache disorder with a major impact on patients' quality of life. This work presents evidence-based recommendations for the treatment of cluster headache derived from a systematic review of the literature and consensus among a panel of experts.

METHODS

The databases PubMed (Medline), Science Citation Index, and Cochrane Library were screened for studies on the efficacy of interventions (last access July 2022). The findings in these studies were evaluated according to the recommendations of the European Academy of Neurology, and the level of evidence was established using GRADE (Grading of Recommendations Assessment, Development, and Evaluation).

RECOMMENDATIONS

For the acute treatment of cluster headache attacks, there is a strong recommendation for oxygen (100%) with a flow of at least 12 L/min over 15 min and 6 mg subcutaneous sumatriptan. Prophylaxis of cluster headache attacks with verapamil at a daily dose of at least 240 mg (maximum dose depends on efficacy and tolerability) is recommended. Corticosteroids are efficacious in cluster headache. To reach an effect, the use of at least 100 mg prednisone (or equivalent corticosteroid) given orally or at up to 500 mg iv per day over 5 days is recommended. Lithium, topiramate, and galcanezumab (only for episodic cluster headache) are recommended as alternative treatments. Noninvasive vagus nerve stimulation is efficacious in episodic but not chronic cluster headache. Greater occipital nerve block is recommended, but electrical stimulation of the greater occipital nerve is not recommended due to the side effect profile.

Gamma Knife radiosurgery for the treatment of cluster headache: a systematic review

Cluster headache (CH) is a severe trigeminal autonomic cephalalgia that, when refractory to medical treatment, can be treated with Gamma Knife radiosurgery (GKRS). The outcomes of studies investigating GKRS for CH in the literature are inconsistent, and the ideal target and treatment parameters remain unclear. The aim of this systematic review is to evaluate the safety and the efficacy, both short and long term, of GKRS for the treatment of drug-resistant CH. A systematic review of the literature was performed to identify all clinical articles discussing GKRS for the treatment of CH. The literature review revealed 5 studies describing outcomes of GKRS for the treatment of CH for a total of 52 patients (48 included in the outcome analysis). The trigeminal nerve, the sphenopalatine ganglion, and a combination of both were treated in 34, 1, and 13 patients. The individual studies demonstrated initial meaningful pain reduction in 60-100% of patients, with an aggregate initial meaningful pain reduction in 37 patients (77%). This effect persisted in 20 patients (42%) at last follow-up. Trigeminal sensory disturbances were observed in 28 patients (58%) and deafferentation pain in 3 patients (6%). Information related to GKRS for CH are limited to few small open-label studies using heterogeneous operative techniques. In this setting, short-term pain reduction rates are high, whereas the long-term results are controversial. GKRS targeted on the trigeminal nerve or sphenopalatine ganglion is associated to a frequent risk of trigeminal disturbances and possibly deafferentation pain.

Vidian Neurectomy for Management of Chronic Cluster Headache

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.

Frovatriptan for the Treatment of Cluster Headaches

Cluster headaches both episodic and chronic are some of the most challenging headaches to treat. Although effective treatments are now available, some patients continue to be unresponsive to standard therapy. We present 17 patients from our practice whom we treated preventively with frovatriptan, a new triptan with a long half-life. The promising results suggest that this medication may be an useful addition to our ammaterium against this painful disorder.

Evidence-based treatments for cluster headache

Cluster headache (CH), one of the most painful syndromes known to man, is managed with acute and preventive medications. The brief duration and severity of the attacks command the use of rapid-acting pain relievers. Inhalation of oxygen and subcutaneous sumatriptan are the two most effective acute therapeutic options for sufferers of CH. Several preventive medications are available, the most effective of which is verapamil. However, most of these agents are not backed by strong clinical evidence. In some patients, these options can be ineffective, especially in those who develop chronic CH. Surgical procedures for the chronic refractory form of the disorder should then be contemplated, the most promising of which is hypothalamic deep brain stimulation. We hereby review the pathogenesis of CH and the evidence behind the treatment options for this debilitating condition.

Supraorbital and supratrochlear stimulation for trigeminal autonomic cephalalgias

Trigeminal autonomic cephalalgias (TAC) is a rare primary headache disorder with challenging and limited treatment options for those unfortunate patients with severe and refractory pain. This article will review the conventional pharmacologic treatments as well as the new neuromodulation techniques designed to offer alternative and less invasive treatments. These techniques have evolved from the treatment of migraine headache, a much more common headache syndrome, and expanded towards application in patients with TAC. Specifically, the article will discuss the targeting of the supratrochlear and supraorbital nerves, both terminal branches of the trigeminal nerve.

Neuromodulation for cephalgias

Headaches (cephalgias) are a common reason for patients to seek medical care. There are groups of patients with recurrent headache and craniofacial pain presenting with malignant course of their disease that becomes refractory to pharmacotherapy and other medical management options. Neuromodulation can be a viable treatment modality for at least some of these patients. We review the available evidence related to the use of neuromodulation modalities for the treatment of medically refractory craniofacial pain of different nosology based on the International Classification of Headache Disorders, 2(nd) edition (ICHD-II) classification. This article also reviews the scientific rationale of neuromodulation application in management of cephalgias.

Treatment of severe trigeminal headache in patients with pituitary adenomas

BACKGROUND

The incidence of headache in patients with pituitary adenomas is high, and the underlying pathological mechanisms are not completely understood.

OBJECTIVE

We tested the efficacy of percutaneous ganglion block and trigeminal rhizotomy in the treatment of severe trigeminal/autonomic headache associated with pituitary tumors.

METHODS

Eleven patients treated surgically for pituitary adenomas in whom intractable trigeminal headaches developed were enrolled in the study and underwent ictal cerebral single-photon emission computed tomography before starting treatment. Initially, all patients underwent a 6-month medical treatment trial. Patients who did not experience improvement in headache severity, addressed by the Headache Impact Test-6 scale, underwent trigeminal percutaneous ganglion blockade. Two patients subsequently underwent trigeminal balloon rhizotomy.

RESULTS

Among the 11 patients, 6 did not have improved Headache Impact Test-6 scale scores after 6 months of treatment with medications and underwent trigeminal ganglion blockade. Significant improvement in headache severity was noted in 3 of them. Long-term response was obtained in 1 patient, and the other 2, in whom the response was transient, were then successfully treated with trigeminal rhizotomy. Cerebral single-photon emission computed tomography showed increased uptake in the thalamus/hypothalamus region in patients who responded well to manipulation of the trigeminal-hypothalamic system.

CONCLUSION

Percutaneous ganglion blockade and trigeminal rhizotomy may be promising alternative options for the treatment of severe headache in selected patients with pituitary adenomas.

Stereotactic radiosurgery for intractable cluster headache: an initial report from the North American Gamma Knife Consortium

Object

The aim of this study was to evaluate the outcomes of Gamma Knife surgery (GKS) when used for patients with intractable cluster headache (CH).

Methods

Four participating centers of the North American Gamma Knife Consortium identified 17 patients who underwent GKS for intractable CH between 1996 and 2008. The median patient age was 47 years (range 26–83 years). The median duration of pain before GKS was 10 years (range 1.3–40 years). Seven patients underwent unsuccessful prior surgical procedures, including microvascular decompression (2 patients), microvascular decompression with glycerol rhizotomy (2 patients), deep brain stimulation (1 patient), trigeminal ganglion stimulation (1 patient), and prior GKS (1 patient). Fourteen patients had associated autonomic symptoms. The radiosurgical target was the trigeminal nerve (TN) root and the sphenopalatine ganglion (SPG) in 8 patients, only the TN in 8 patients, and only the SPG in 1 patient. The median maximum TN and SPG dose was 80 Gy.

Results

Favorable pain relief (Barrow Neurological Institute Grades I–IIIb) was achieved and maintained in 10 (59%) of 17 patients at a median follow-up of 34 months. Three patients required additional procedures (repeat GKS in 2 patients, hypothalamic deep brain stimulation in 1 patient). Eight (50%) of 16 patients who had their TN irradiated developed facial sensory dysfunction after GKS.

Conclusions

Gamma Knife surgery for intractable, medically refractory CH provided lasting pain reduction in approximately 60% of patients, but was associated with a significantly greater chance of facial sensory disturbances than GKS used for trigeminal neuralgia.

Giant internal carotid artery aneurysm manifesting as difficulty in swallowing: case report

A 66-year-old man presented with a rare case of a giant aneurysm of the internal carotid artery manifesting as difficulty in swallowing, resulting in severe malnutrition. Initial examination found a pulsating mass protruding from the posterior wall of the pharynx in the oral cavity. The patient had left hemiplegia caused by cerebral infarction one year previously. The patient underwent surgical therapy consisting of superficial temporal artery-middle cerebral artery bypass and trapping of the internal carotid artery. The pulsation of the oral mass vanished just after surgery and his difficulty in swallowing gradually improved. The patient was discharged with no new neurological deficits. The previous cerebral infarction was probably caused by an embolus from this giant aneurysm.

Destructive procedures for the treatment of nonmalignant pain: a structured literature review

OBJECT

Nonmalignant pain has been treated in the past century with ablative, or more appropriately, destructive procedures. Although individual outcomes for these procedures have previously been described in the literature, to the authors' knowledge this is the first comprehensive and systematic review on this topic.

METHODS

A US National Library of Medicine PubMed search was conducted for the following ablative procedures: cingulotomy, cordotomy, DREZ (also input as dorsal root entry zone), ganglionectomy, mesencephalotomy, myelotomy, neurotomy, rhizotomy, sympathectomy, thalamotomy, and tractotomy. Articles related to pain resulting from malignancy and those not in peer-reviewed journals were excluded. In reviewing pertinent articles, focus was placed on patient number, outcome, and follow-up.

RESULTS

A total of 146 articles was included in the review. The large majority of studies (131) constituted Class III evidence. Eleven Class I and 4 Class II studies were found, of which nearly all (13 of 15) evaluated radiofrequency rhizotomies for different pain origins, including lumbar facet syndrome, cervical facet pain, and Type I or typical trigeminal neuralgia. Overall, support for ablative procedures for nonmalignant pain is derived almost entirely from Class III evidence; despite a long history of use in neurosurgery, the evidence supporting destructive procedures for benign pain conditions remains limited.

CONCLUSIONS

Newly designed prospective standardized studies are required to define surgical indications and outcomes for these procedures, to provide more systematic review, and to advance the field.

Sphenopalatine ganglion radiofrequency ablation for the management of chronic cluster headache

OBJECTIVES

Chronic cluster headache patients are often resistant to pharmacological management. Percutaneous radiofrequency ablation (RFA) of the sphenopalatine ganglion (SPG) was shown before to improve episodic cluster headache but not chronic cluster headache. We were interested to examine the effect of such intervention in patients with intractable chronic cluster headache who failed pharmacological management.

METHODS

Fifteen patients with chronic cluster headache, who experienced temporary pain relief following SPG block, underwent percutaneous RFA via the infrazygomatic approach under fluoroscopic guidance. Collected data include demographic variables, onset and duration of the headache, mean attack intensity (MAI), mean attack frequency (MAF), and pain disability index (PDI) before and up to 18 months after procedure.

RESULTS

At 1-, 3-, 6-, 12-, 18-month follow-up, the MAI was 2.6, 3.2, 3.2, 3.4, 4.2, respectively (P < .0001, P < .0001, P < .0001, P < .0005, P < .003, respectively). The PDI improved from 55 (baseline) to 17.2 and 25.6 at 6 and 12 months respectively (P < .001). The MAF improved from 17 attacks/week to 5.4, 6.4, 7.8, 8.6, 8.3 at 1-, 3-, 6-, 12-, 18-month follow-up visits (P < .0001, P < .0001, P < .0001, P < .002, P < .004, respectively).

CONCLUSION

Our data showed that percutaneous RFA of the SPG is an effective modality of treatment for patients with intractable chronic cluster headaches. Precise needle placement with the use of real-time fluoroscopy and electrical stimulation prior to attempting radiofrequency lesioning may reduce the incidence of adverse events.

Cluster headache

Cluster headache (CH) is a primary headache disease characterized by recurrent short-lasting attacks (15 to 180 minutes) of excruciating unilateral periorbital pain accompanied by ipsilateral autonomic signs (lacrimation, nasal congestion, ptosis, miosis, lid edema, redness of the eye). It affects young adults, predominantly males. Prevalence is estimated at 0.5–1.0/1,000. CH has a circannual and circadian periodicity, attacks being clustered (hence the name) in bouts that can occur during specific months of the year. Alcohol is the only dietary trigger of CH, strong odors (mainly solvents and cigarette smoke) and napping may also trigger CH attacks. During bouts, attacks may happen at precise hours, especially during the night. During the attacks, patients tend to be restless. CH may be episodic or chronic, depending on the presence of remission periods. CH is associated with trigeminovascular activation and neuroendocrine and vegetative disturbances, however, the precise cautive mechanisms remain unknown. Involvement of the hypothalamus (a structure regulating endocrine function and sleep-wake rhythms) has been confirmed, explaining, at least in part, the cyclic aspects of CH. The disease is familial in about 10% of cases. Genetic factors play a role in CH susceptibility, and a causative role has been suggested for the hypocretin receptor gene. Diagnosis is clinical. Differential diagnoses include other primary headache diseases such as migraine, paroxysmal hemicrania and SUNCT syndrome. At present, there is no curative treatment. There are efficient treatments to shorten the painful attacks (acute treatments) and to reduce the number of daily attacks (prophylactic treatments). Acute treatment is based on subcutaneous administration of sumatriptan and high-flow oxygen. Verapamil, lithium, methysergide, prednisone, greater occipital nerve blocks and topiramate may be used for prophylaxis. In refractory cases, deep-brain stimulation of the hypothalamus and greater occipital nerve stimulators have been tried in experimental settings. The disease course over a lifetime is unpredictable. Some patients have only one period of attacks, while in others the disease evolves from episodic to chronic form.

Percutaneous balloon compression for trigeminal neuralgias and autonomic cephalalgia

OBJECTIVE

This prospective study aimed to evaluate the results of percutaneous trigeminal ganglion balloon compression (BC) in patients with various types of trigeminal neuralgia (TN) and autonomic cephalalgia.

METHODS

Twenty-five consecutive patients underwent BC and were followed up for 27-60 months. They were divided into 2 groups: group A (n=18) patients with idiopathic TN and group B (n=7) patients with secondary TN (n=5) and trigeminal autonomic cephalalgia (TAC) (n=2).

RESULTS

Postoperatively, 15 patients in group A experienced pain relief, one required medication and 2 had no response; in group B, 6 were free of pain, including the 2 patients with TAC, and one required medication. Complications in both groups were either functionally trivial or infrequent. None of the patients developed keratitis or anesthesia dolorosa. Pain recurrence occurred early (<6 months) in one patient from group B, and late in 2 patients from group A.

CONCLUSION

Balloon compression is a minimally invasive procedure that seems to be comparably successful for idiopathic and secondary TN, as well as TAC. However, further studies are deemed necessary to establish it as the first-line treatment in medically resistant trigeminal pain.

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.

Chronic cluster headache: New and emerging treatment options

Cluster headache (CH) is a primary headache syndrome characterized by short-lasting unilateral head pain attacks accompanied by ipsilateral oculofacial autonomic phenomena. Approximately 20% of CH patients have the chronic form and need continuous medical care. In the chronic form, attacks continue unabated for years, often on a daily basis, resulting in severe debilitation. It is a common experience that drug treatments are able to control or prevent the attacks in approximately 80% of chronic CH patients. In the remaining 20% of chronic cases, drugs are ineffective. Until recently, the etiology of CH was poorly understood and this hampered the development of new therapies. However, we have now gained a much improved understanding of the peripheral and central mechanisms giving rise to the pain in CH and this has inspired the development of new treatment approaches, which, although still in the initial phases of validation, appear to be very promising. Among these, the novel approach based on hypothalamic deep brain stimulation is one of the most promising.

Cluster headache

Cluster headache is a relatively rare episodic headache disorder.Although traditionally it is believed to be a male-related disorder,the sex ratios are changing toward a more even balance. The disorder is characterized by bouts of daily headaches with pain-free remissions for extended times. Though attacks are brief, they are severe and typically are associated with autonomic symptoms. Medical therapies are the mainstay of treatment, with the goal being prevention of headaches in a cycle. Acute therapies, although effective, may be limited in usefulness because of attack frequency. Intractable cases may benefit from histamine desensitization and surgical treatments.

Cluster Headache and Cluster Variants

Patients must be cognizant of the time course of the cluster headache periods to optimally tailor their therapy. Steroids provide the fastest onset of prophylactic effect. Once steroids are initiated, it remains difficult to wean patients off of them, and that is why it is always recommended to associate another prophylactic agent from the onset with the steroids. All triptans can be considered; however, only injectable sumatriptan and zolmitriptan have been the subject of controlled studies, and the former remains the gold standard because of its speed of action. Lithium, although not a first-line therapy, remains mainly efficacious for the chronic form of cluster headache. There does not seem a significant tendency for analgesic rebound-withdrawal headache with cluster headache compared with migraine. Scientific studies of the treatment of cluster headache are inherently difficult because of the rarity of the syndrome, the short duration of attacks, and the relatively short duration of the cluster period, along with the presence of spontaneous remissions. Moreover, still a significant proportion of the available evidence on this subject is uncontrolled. Active, rather than placebo, control individuals are recommended. As far as surgical procedures are concerned, although only recently introduced and less documented, gamma-knife radiosurgery should be preferred to the procedures associated with craniotomy, which are inherently associated with a higher complication potential risk.

Stimulation of the Posterior Hypothalamus for Treatment of Chronic Intractable Cluster Headaches: First Reported Series

OBJECTIVE

To describe the results of deep brain stimulation of the ipsilateral posterior hypothalamus for the treatment of drug-resistant chronic cluster headaches (CHs). A technique for electrode placement is reported.

METHODS

Because recent functional studies suggested hypothalamic dysfunction as the cause of CH bouts, we explored the therapeutic effectiveness of posterior hypothalamic stimulation for the treatment of CHs. Five patients with intractable chronic CHs were treated with long-term, high-frequency, electrical stimulation of the posterior hypothalamus. Electrodes were stereotactically implanted in the following position: 3 mm behind the midcommissural point, 5 mm below the midcommissural point, and 2 mm lateral to the midline.

RESULTS

Since this treatment, all five patients continue to be pain-free after 2 to 22 months of follow-up monitoring. Two of the five patients have remained pain-free without any medication, whereas three of the five required low doses of methysergide (two patients) or verapamil (one patient). No adverse side effects of chronic, high-frequency, hypothalamic stimulation have been observed, and we have not encountered any acute complications resulting from the implant procedure. There have been no tolerance phenomena.

CONCLUSION

These preliminary results indicate a role for posterior hypothalamic stimulation, which was demonstrated to be safe and effective, in the treatment of drug-resistant chronic CHs. These data point to a central pathogenesis for chronic CHs.

Operative management of skull base malignancies: choosing the appropriate approach

Malignant tumors of the skull base are complex lesions. Identifying the indications and contraindications for resection is essential for the successful treatment of these lesions. This requires an understanding of the pathology, principles of resection, and nonsurgical therapeutic modalities. Choosing the appropriate surgical approach requires an understanding of the tumor and its association with the anatomy of the skull base. Preoperative assessment and preparation of the patient for the postoperative course, including functional and cosmetic deficits, are reviewed in the context of the specific approach. Anatomical variations encountered in the preoperative planning are discussed. A review of reconstructive alternatives is presented that is specific to the approach and anatomical violation. Finally, the use of a multidisciplinary team both in and out of the operating room is recommended, emphasizing a team approach during the resection itself.

New treatments in cluster headache

Cluster headache is the most severe headache syndrome known to humans. In most instances, this disorder is readily treatable when the correct medications are utilized at the correct dosages. Cluster treatment involves abortive, transitional, and preventive therapy strategies, all of which are discussed in this article.

Interventional treatment for cluster headache: a review of the options

There is no more severe pain than that sustained by a cluster headache sufferer. Surgical treatment of cluster headache should only be considered after a patient has exhausted all medical options or when a patient's medical history precludes the use of typical cluster abortive and preventive medications. Once a cluster patient is deemed a medical failure only those who have strictly side-fixed headaches should be considered for surgery. Other criteria for cluster surgery include pain localizing to the ophthalmic division of the trigeminal nerve, a psychologically stable individual, and absence of addictive personality traits. To understand the rationale behind the surgical treatment strategies for cluster, one must have a general understanding of the anatomy of cluster pathogenesis. The most frequently used surgical techniques for cluster are directed toward the sensory trigeminal nerve and the cranial parasympathetic system.

Neurolysis of the Trigeminal and Sphenopalatine Ganglions

Facial pain of trigeminal and sphenopalatine ganglion origin is the bain of existence for thousands of people. Treatment protocols typically begin with oral medication, usually anticonvulsants, and may progress to percutaneous and open surgical procedures. Several new medications show promise as alternatives to carbamazepine, which has been the standard first-line treatment (trigeminal neuralgia), while electromagnetic pulsed radiofrequency and gamma knife surgery are new options when the surgical route is warranted. This article will examine the anatomy of the trigeminal and sphenopalatine ganglions. Indications for neurolysis and neurolytic options will be discussed. Efficacy of the various neurolytic techniques will be thoroughly reviewed.