Long-term Outcomes of Computerized Tomography-Guided Sphenopalatine Ganglion-Targeted Pulsed Radiofrequency for Refractory Cluster Headache

15. Cluster Headache

INTRODUCTION

Cluster headache is a rare primary headache disorder characterized by excruciating unilateral pain around the eye, lasting between 15 and 180 min, accompanied by ipsilateral cranial autonomic symptoms. Cluster headache is classified into two forms: episodic and chronic, with chronic cluster headache defined by pain-free intervals of less than 3 months between bouts. Both drug-based and invasive treatments are available for abortive and preventive purposes. Treatment selection depends on individual efficacy and tolerance, with invasive options considered when pharmacological treatments prove ineffective.

METHODS

This narrative review summarizes the literature on common practice and the evidence in the treatment of cluster headache.

RESULTS

Oxygen therapy and subcutaneous sumatriptan are the most effective abortive treatments for cluster headache. Oral corticosteroid tapering regimens can be used as bridging therapy. Verapamil, lithium, topiramate, and CGRP antagonists are potential preventive medication options. Greater occipital nerve (GON) injections and radiofrequency (RF) therapy can be used as preventive treatments, though their effects are often temporary. For refractory chronic cluster headache, occipital nerve stimulation (ONS) has proven to be effective. Deep brain stimulation (DBS) may also be considered if all other treatments have failed.

CONCLUSIONS

The management of cluster headache is complex due to the variable efficacy of treatments across different patients and limited evidence.

Ultrasound guided pulsed radiofrequency neuromodulation of sphenopalatine ganglion treatment for allergic rhinitis in childern: A case report

Allergic rhinitis (AR) is a chronic noninfectious inflammation of the nasal mucosa mediated primarily by allergen-specific immunoglobulin E (IgE) in atopic individuals after exposure to allergens, with the involvement of non-IgE-mediated mechanisms and neuroimmune dysregulation. Conservative treatment of AR is ineffective in children who lack compliance, and traditional surgical procedures are risky, making treatment of this community challenging. The sphenopalatine ganglion (SPG), aka pterygopalatine ganglion, is the largest of the four parasympathetic ganglia located within the head region, existing as a bilateral pair. The fibers that arise from the SPG regulate secretomotor functions and provide sensation from various structures, including the lacrimal glands, the mucous membranes of the oropharynx, nasopharynx, nasal cavity, and upper portion of the oral cavity. Previous studies suggest that SPG plays a much crucial role in the neuro-related pathophysiological mechanisms of AR. Pulsed radiofrequency (PRF) is a commonly used technique in pain management to produce neuromodulatory effects without damaging nerve tissue. Previous research suggests that SPG dysfunction is one of the important pathophysiological mechanisms of trigeminal autonomic cephalalgia, and PRF targeting SPG can effectively exert neuromodulatory effects to improve its symptoms. We thus predicted that the application of PRF for neuromodulation of SPG would be beneficial for symptom remission in AR. We report the first case of AR successfully treated with PRF targeting the SPG, symptoms did ameliorate during the 24-week follow-up period, as manifested by the disappearance of nocturnal open-mouth breathing and its murmur and a significant reduction in the frequency and severity of daily episodes of nasal congestion, tearing, and conjunctival congestion, which diversifies clinical interventions for AR.

Ocular involvement in sphenopalatin ganglion pulsed radiofrequency

Pulsed radiofrequency (PRF) treatment of the sphenopalatine ganglion is an important interventional treatment in refractory cases of trigeminal neuralgia (TN) or atypical facial pain, given the easy access to its location. Despite the fact that complications from this technique are rare and it is a fairly safe procedure, ophthalmologists should know about it due to the anatomical relations of this ganglion.

Preventive treatment of refractory chronic cluster headache: systematic review and meta-analysis

BACKGROUND

Preventive treatment for refractory chronic cluster headache (rCCH) is challenging and many therapies have been tried.

OBJECTIVE

To study what could be considered the therapy of choice in rCCH through a systematic review and meta-analysis.

METHODS

This review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The protocol was registered in PROSPERO (ID CRD42021290983). A systematic search was performed in MEDLINE, Embase, Cochrane, clinicaltrials.gov, and the WHO's-International-Clinical-Trials-Registry-Platform. Studies on the preventive treatment for rCCH as defined by the European Headache Federation consensus statement were included. A meta-analysis of the pooled response rate was conducted for the different therapies.

RESULTS

Of 336 results, 45 were eligible for inclusion. Most articles studied the effect of neuromodulation as a preventive treatment for rCCH. The most studied neuromodulation technique was occipital nerve stimulation (ONS), with a pooled response rate in the meta-analysis of 57.3% (95% CI 0.481-0.665). Deep brain stimulation (DBS) was the second most studied treatment with a pooled response rate of 77.0% (95% CI 0.594-0.957). DBS results were more heterogeneous than ONS, which could be related to the different stimulation targets in DBS studies, and reported more serious adverse events than in ONS studies. The remaining therapies (anti-CGRP pathway drugs, warfarin, ketamine-magnesium infusions, serial occipital nerve blocks, clomiphene, onabotulinum toxin A, ketogenic diet, sphenopalatine ganglion radiofrequency or stimulation, vagus nerve stimulation, percutaneous bioelectric current stimulation, upper cervical cord stimulation, and vidian neurectomy) present weaker results or have less quality of evidence.

CONCLUSIONS

The results of this systematic review and meta-analysis suggest that ONS could be the first therapeutic strategy for patients with rCCH based on the current evidence.

Sphenopalatine ganglion-targeted low-temperature plasma radiofrequency ablation in the treatment of refractory cluster headache

Introduction

Cluster headache (CH) is a refractory headache. Low-temperature plasma radiofrequency ablation is a relatively novel technique with promising applications in neuropathic pain. It may improve the treatment of CH.

Aim

To evaluate the efficacy and safety of sphenopalatine ganglion-targeted low-temperature plasma radiofrequency ablation in the treatment of patients with refractory CH.

Material and methods

A retrospective cohort study including seventy-five patients with refractory cluster headache who underwent computed tomography (CT)-guided sphenopalatine ganglion-targeted low-temperature plasma radiofrequency ablation between January 2015 and December 2017 at the Beijing Xuanwu Hospital was conducted.

Results

Effective pain relief rate 3 months after the procedure was 96% with 40 (53.3%) patients achieving complete relief; 32 (42.7%) patients obtained partial relief and 3 (4%) patients showed no relief. The effective pain relief rate two years after the procedure remained as high as 85.3% with 29 (38.6%) achieving complete relief, 35 (46.7%) partial relief and 11 (14.7%) no relief. The procedure proved equally effective for both episodic and chronic cluster headache. Complications including facial numbness, masseter weakness, facial hypoesthesia and cheek hematoma were observed, but all were mild and disappeared within 6 months.

Conclusions

CT-guided low-temperature plasma radiofrequency ablation is an effective and safe strategy for refractory cluster headache. For patients who have not responded to conservative treatment, this minimally invasive intervention is a reliable alternative.