Alternative Relief for Cluster Headache

ABSTRACT & COMMENTARY

Source: Sanders M, Zuurmond W. Efficacy of sphenopalatine ganglion blockade in 66 patients suffering from cluster headache: A 12- to 70-month follow-up evaluation. J Neurosurg 1997;87:876-860.

Pharmacologic treatment has been the standard of therapy for episodic and chronic cluster headache (CH). Despite the efficacy of medications such as ergotamines, sumatriptan, corticosteroids, methysergide, lithium, and calcium channel blockers, CH remains refractory in 5-15% of cases. Since the sphenopalatine ganglion (SPG) has been implicated in the origin of cluster headache, alternative invasive treatments have been studied. Sanders and Zuurmond report on their six-year experience using radio frequency (RF) lesioning to the SPG in medically refractory patients.

A total of 66 patients (55 male and 11 female) in whom medical therapy proved inadequate underwent percutaneous RF of the SPG. The groups were divided into episodic CH (56 patients) and chronic CH (10 patients). Patients received a maximum of three treatments within one-month intervals. Follow-up ranged from 12 to 70 months. Relief was judged complete if there was no pain and withdrawal of medication. Partial pain relief was defined as a greater than 50% reduction in medication as well as a decrease in the number, duration, and intensity of CH attacks. Their results are shown in the table.

Table

Relief from cluster headache

Cluster-Mean Complete Partial No Typefollow-upReliefReliefRelief

Episodic 56 29.1 ± 10.6 34 (61%) 14 (25%) 8 (14%)

Chronic 10 24.0 ± 9.7 3 (30%) 3 (30%) 4 (40%)

The authors report limited adverse effects and complications. Eight patients experienced temporary post-operative epistaxis, and 11 patients developed cheek hematomas. Four patients had inadvertent RF lesions to the maxillary nerve and subsequent maxillary hyperpathia. Nine patients reported hypesthesia of the palate that completely resolved in three months.

The long-term follow-up ensures that the treatment response was not explained by the natural waxing and waning of the condition. The authors conclude that RF to the SPG for treatment of episodic CH is both effective and safe. Because of the small number of patients, conclusions about the chronic CH group are less sure.

COMMENTARY

There have been many invasive methods attempted to relieve the pain of CH.^1-4 Initially, surgical removal of the SPG, the greater superficial petrosal, and trigeminal and intermediate nerves was performed. Eventually, injection procedures such as glycerol, alcohol, lidocaine, and cocaine applied to either the trigeminal nerve and/or the SPG were tried. All of these studies involved small numbers of patients without blinded controls. Anesthetic injections resulted at best in partial pain relief and high recurrence rates. The surgical procedures required major intervention and significant morbidity. However, as this study suggests, selective blockade with RF lesioning may be the most effective and best tolerated option once medication fails. A more rigorous randomized, blinded study to compare the efficacy of pharmacologic and RF lesioning is needed. jr

References

1. Ekbom K, et al. Retro-Gasserian glycerol injection in the treatment of chronic cluster headache. Cephalalgia 1987;7:21-27.

2. Harris W, et al. Alcohol injection of the Gasserian ganglion for migrainous neuralgia. Lancet 1940;2:481-482.

3. Gardner WJ, et al. Resection of the greater superficial petrosal nerve in the treatment of unilateral headache. J Neurosurgery 1947;4:105-114.

4. Kittrelle JP, et al. Cluster headache. Local anaesthetic abortive agents. Arch Neurol 1985;42:496-498.

Despite the efficacy of medications such as sumatriptan, corticosteroids, ergotamines, and lithium, cluster headache remains refractory in what percentage of cases?

a. 3-5%

b. 15-20%

c. 5-15%

d. 25-30%