Efficacy and safety of surgical treatment of cluster headache

Cluster headache: understandings of current knowledge and directions for whole process management

Cluster headache (CH) is a common primary headache that severely impacts patients' quality of life, characterized by recurrent, severe, unilateral headaches often centered around the eyes, temples, or forehead. Distinguishing CH from other headache disorders is challenging, and its pathogenesis remains unclear. Notably, patients with CH often experience high levels of depression and suicidal tendencies, necessitating increased clinical attention. This comprehensive assessment combines various reports and the latest scientific literature to evaluate the current state of CH research. It covers epidemiology, population characteristics, predisposing factors, and treatment strategies. Additionally, we provide strategic insights into the holistic management of CH, which involves continuous, individualized care throughout the prevention, treatment, and rehabilitation stages. Recent advances in the field have revealed new insights into the pathophysiology of CH. While these findings are still evolving, they offer a more detailed understanding of the neurobiological mechanisms underlying this disorder. This growing body of knowledge, alongside ongoing research efforts, promises to lead to the development of more targeted and effective treatments in the future.

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.

CT-Guided Thermocoagulation of the Pterygopalatine Ganglion for Refractory Trigeminal Autonomic Cephalalgia

INTRODUCTION

Trigeminal autonomic cephalalgia (TAC) is a type of one-sided cerebral painful headache, with attacks regularly accompanied by autonomic responses, such as tearing, runny nose, panic, nausea and vomiting on the affected side. Currently, the most common treatment strategies are drugs, nerve grafts and surgery. Clinical understanding of TACs is limited. Here, we report the case of thermocoagulation treatment of the pterygopalatine ganglion in an uncommon TAC under local anesthesia.

CASE PRESENTATION

A rare case of TAC was treated with computed tomography (CT)-guided thermocoagulation within the pterygopalatine ganglion. Pain and autonomic signs were relieved immediately after surgery, with the patent retaining only slight numbness on the left side of the face. This numbness completely resolved at 6 months of follow-up and there was no recurrence.

DISCUSSION

Trigeminal autonomic cephalalgia seriously affects the patient's quality of life, but clinical understanding is limited. In the case reported here, we performed CT-guided thermocoagulation of the pterygopalatine ganglion at 90 °C for 180 s for treatment of a trigeminal autonomic headache. To our knowledge, this is the first report of using thermocoagulation at 90 °C to treat the pterygopalatine ganglion. We found that this strategy results in fewer side effects and is a more cost-effective treatment for such patients than other options.

CONCLUSION

Computed tomography-guided thermocoagulation of the pterygopalatine ganglion at 90 °C for 180 s for treatment of trigeminal autonomic headache is a safe and economical treatment option.

Neurostimulation Treatment in Chronic Cluster Headache-a Narrative Review

PURPOSE OF REVIEW

In this narrative review, the current literature on neurostimulation methods in the treatment of chronic cluster headache is evaluated. These neurostimulation methods include deep brain stimulation, vagus nerve stimulation, greater occipital nerve stimulation, sphenopalatine ganglion stimulation, transcranial magnetic stimulation, transcranial direct current stimulation, supraorbital nerve stimulation, and cervical spinal cord stimulation.

RECENT FINDINGS

Altogether, only nVNS and SPG stimulation are supported by at least one positive sham-controlled clinical trial for preventive and acute attack (only SPG stimulation) treatment. Other clinical trials either did not control at all or controlled by differences in the stimulation technique itself but not by a sham-control. Case series report higher responder rates. The evidence for these neurostimulation methods in the treatment of chronic cluster headache is poor and in part contradictive. However, except deep brain stimulation, tolerability and safety of these methods are good so that in refractory situations application might be justified in individual cases.

Occipital Nerve Stimulation for Pain Modulation in Drug-Resistant Chronic Cluster Headache

Occipital nerve stimulation (ONS) is a surgical treatment proposed for drug-resistant chronic cluster headache (drCCH). Long-term series assessing its efficacy are scarce. We designed a retrospective observational study with consecutive sampling, evaluating the follow-up of 17 drCCH patients who underwent ONS. Our main endpoint was the reduction the rate of attacks per week. We also evaluated the pain intensity through the Visual Analogue Scale (VAS), patient overall perceived improvement and decrease in oral medication intake. After a median follow-up of 6.0 years (4.5–9.0), patients decreased from a median of 30 weekly attacks to 22.5 (5.6–37.5, p = 0.012), 7.5 at 1 year (p = 0.006) and 15.0 at the end of follow-up (p = 0.041). The VAS decreased from a median of 10.0 to 8.0 (p = 0.011) at three months, to 7.0 (p = 0.008) at twelve months and 7.0 (p = 0.003) at the end of the follow-up. A total of 23.5% had an overall perceived improvement of ≥70% at 3 months, 41.2% at 1 year and 27.8% at the end of follow-up. Reducing prophylactic oral medication was possible in 76.5% and it was stopped in 17.7%. Triptan use decreased in all the responder patients and 17.7% stopped its intake. A total of 41.2% presented mild adverse events. In conclusion, our long-term experience suggests that ONS could be an interesting option for drCCH-selected patients, as it is a beneficial and minimally invasive procedure with no serious adverse events.

Neuromodulation in headache and craniofacial neuralgia: guidelines from the Spanish Society of Neurology and the Spanish Society of Neurosurgery

INTRODUCTION

Numerous invasive and non-invasive neuromodulation devices have been developed and applied to patients with headache and neuralgia in recent years. However, no updated review addresses their safety and efficacy, and no healthcare institution has issued specific recommendations on their use for these 2 conditions.

METHODS

Neurologists from the Spanish Society of Neurology's (SEN) Headache Study Group and neurosurgeons specialising in functional neurosurgery, selected by the Spanish Society of Neurosurgery (SENEC), performed a comprehensive review of articles on the MEDLINE database addressing the use of the technique in patients with headache and neuralgia.

RESULTS

We present an updated review and establish the first set of consensus recommendations of the SEN and SENC on the use of neuromodulation to treat headache and neuralgia, analysing the current levels of evidence on its effectiveness for each specific condition.

CONCLUSIONS

Current evidence supports the indication of neuromodulation techniques for patients with refractory headache and neuralgia (especially migraine, cluster headache, and trigeminal neuralgia) selected by neurologists and headache specialists, after pharmacological treatment options are exhausted. Furthermore, we recommend that invasive neuromodulation be debated by multidisciplinary committees, and that the procedure be performed by teams of neurosurgeons specialising in functional neurosurgery, with acceptable rates of morbidity and mortality.