Occipital Injections for Trigemino-Autonomic Cephalalgias: Evidence and Uncertainties

[Trigeminal Autonomic Cephalgias]

Compared with migraine and tension-type headache, trigeminal autonomic cephalgias (TAC) are rare, but the resulting significant impairment and the not irrelevant prevalence (e. g., cluster headache 0.1%) make TACs important diagnoses. Unfortunately, the correct diagnosis is often delayed. This article provides an overview of the diagnostic approach and therapeutic options in TACs.

Diagnostic protocols and newer treatment modalities for cluster headache

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.

Post-traumatic cephalalgia

After traumatic brain injury (TBI), a host of symptoms of varying severity and associated functional impairment may occur. One of the most commonly encountered and challenging to treat are the post-traumatic cephalalgias. Post-traumatic cephalalgia (PTC) or headache is often conceptualized as a single entity as currently classified using the ICHD-3. Yet, the terminology applicable to the major primary, non-traumatic, headache disorders such as migraine, tension headache, and cervicogenic headache are often used to specify the specific type of headache the patients experiences seemingly disparate from the unitary definition of post-traumatic headache adopted by ICHD-3. More complex post-traumatic presentations attributable to brain injury as well as other headache conditions are important to consider as well as other causes such as medication overuse headache and medication induced headache. Treatment of any post-traumatic cephalalgia must be optimized by understanding that there may be more than one headache pain generator, that comorbid traumatic problems may contribute to the pain presentation and that pre-existing conditions could impact both symptom complaint, clinical presentation and recovery. Any treatment for PTC must harmonize with ongoing medical and psychosocial aspects of recovery.

Pulsed radiofrequency on the occipital nerve for treatment of short-lasting unilateral neuralgiform headache: A case report

Short-lasting unilateral neuralgiform headache (Short-lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing (SUNCT)/Short-lasting Unilateral Neuralgiform headache attacks with Autonomic Symptoms) is a trigeminal autonomic cephalalgia with difficult treatment and its management is based on neuromodulator drugs and sometimes ablative procedures on the trigeminal nerve. A positive response to occipital anesthetic blocks and peripheral and deep neurostimulation has also been described. We present the case of a patient with criteria of left SUNCT and transient response to occipital anesthetic blocks, satisfactorily controlled with pulsed radiofrequency (PRF) of the occipital nerve. Upon examination, the patient had tenderness in the left greater occipital nerve (GON). Blockade was performed with anesthetic and corticosteroid, obtaining a highly positive but transient response. After several nerve blocks, the patient was referred to the Pain Unit where pulsed radiofrequency on the left GON was performed. After two sessions, more than 90% of reduction of pain was achieved, maintained for 12 months. There haven’t been found data in the literature on the use of GON PRF for the treatment of SUNCT, while there are descriptions for other types of cranial pain. The intention of our case is to make this procedure to be considered as an alternative for the treatment of this entity in patients who respond to anesthetic blocks.

Pharmacotherapy for Cluster Headache

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.

Cluster Headache and Other Trigeminal Autonomic Cephalalgias

PURPOSE OF REVIEW

This article covers the clinical features, differential diagnosis, and management of the trigeminal autonomic cephalalgias (TACs). The TACs are composed of five diseases: cluster headache, paroxysmal hemicrania, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT), short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA), and hemicrania continua.

RECENT FINDINGS

New classifications for the TACs have two important updates; chronic cluster headache is now defined as remission periods lasting less than 3 months (formerly less than 1 month), and hemicrania continua is now classified as a TAC (formerly classified as other primary headache). The first-line treatments of TACs have not changed in recent years: cluster headache is managed with oxygen, triptans, and verapamil; paroxysmal hemicrania and hemicrania continua are managed with indomethacin; and SUNCT and SUNA are managed with lamotrigine. However, advancements in neuromodulation have recently provided additional options for patients with cluster headache, which include noninvasive devices for abortive therapy and invasive devices for refractory cluster headache. Patient selection for these devices is key.

SUMMARY

The TACs are a group of diseases that appear similar to each other and to other headache disorders but have important differences. Proper diagnosis is crucial for proper treatment. This article reviews the pathophysiology, epidemiology, differential diagnosis, and treatment of the TACs.

Invasive pericranial nerve interventions

Background

In many patients suffering from primary headaches, the available pharmacological and behavioural treatments are not satisfactory. This is a review of (minimally) invasive interventions targeting pericranial nerves that could be effective in refractory patients.

Methods

The interventions we will cover have in common pericranial nerves as targets, but are distinct according to their rationale, modality and invasiveness. They range from nerve blocks/infiltrations to the percutaneous implantation of neurostimulators and surgical decompression procedures. We have critically analysed the published data (PubMed) on their effectiveness and tolerability.

Results and conclusions

There is clear evidence for a preventative effect of suboccipital injections of local anaesthetics and/or steroids in cluster headache, while evidence for such an effect is weak in migraine. Percutaneous occipital nerve stimulation (ONS) provides significant long-term relief in more than half of drug-resistant chronic cluster headache patients, but no sham-controlled trial has tested this. The evidence that ONS has lasting beneficial effects in chronic migraine is at best equivocal. Suboccipital infiltrations are quasi-devoid of side effects, while ONS is endowed with numerous, though reversible, adverse events. Claims that surgical decompression of multiple pericranial nerves is effective in migraine are not substantiated by large, rigorous, randomized and sham-controlled trials.

Occipital Nerve Blocks for Pediatric Posttraumatic Headache: A Case Series

Posttraumatic headache is one of the most common and disabling symptoms after traumatic brain injury. However, evidence for treating posttraumatic headache is sparse, especially in the pediatric literature. This retrospective chart review evaluated the use of occipital nerve blocks in adolescents treated for posttraumatic headache following mild traumatic brain injury, presenting to the Complex Concussion and Traumatic Brain Injury clinic. Fifteen patients (mean age 15.47; range: 13-17) received occipital nerve block for posttraumatic headache. Follow-up was obtained in 14 patients at 5.57 (standard deviation = 3.52) months postinjury. The headache burden was high, with all except one having headaches 15 or more days per month (median 30, range 10-30). Sixty-four percent reported long-term response to the occipital nerve blocks, with associated improved quality of life and decreased postconcussion symptom scores (P < .05). One patient reported transient allopecia. Occipital nerve blocks are well tolerated and can be helpful in posttraumatic headache.

Cluster headache: conventional pharmacological management

Cluster headache pain is very intense, usually increases in intensity very rapidly from onset, and attacks are often frequent. These clinical features result in significant therapeutic challenges. The most effective pharmacological treatment options for acute cluster attack include subcutaneous sumatriptan, 100% oxygen, and intranasal zolmitriptan. Subcutaneous or intramuscular dihydroergotamine and intranasal sumatriptan are additional options. Transitional therapy is applicable mainly for patients with high-frequency (>2 attacks per day) episodic cluster headache, and options include short courses of high-dose oral corticosteroids, dihydroergotamine, and occipital nerve blocks with local anesthetic and steroids. Prophylactic therapy is important both for episodic and chronic cluster headache, and the main options are verapamil and lithium. Verapamil is drug of first choice but may cause cardiac arrhythmias, and periodic electrocardiograms (EKGs) during dose escalation are important. Many other drugs are also in current use, but there is an insufficient evidence base to recommend them.