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Qin L, Chen D, Li X, Gao Y, Xia W, Dai H, Qiu L, Yang J, Zhang L. Sphenopalatine ganglion stimulation: a comprehensive evaluation across diseases in randomized controlled trials. Front Neurol 2024; 15:1352145. [PMID: 38813242 PMCID: PMC11135047 DOI: 10.3389/fneur.2024.1352145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 05/02/2024] [Indexed: 05/31/2024] Open
Abstract
Background Current literature extensively covers the use of sphenopalatine ganglion stimulation (SPGs) in treating a broad spectrum of medical conditions, such as allergic rhinitis, cluster headaches, and strokes. Nevertheless, a discernible gap in the systematic organization and analysis of these studies is evident. This paper aims to bridge this gap by conducting a comprehensive review and analysis of existing literature on SPGs across various medical conditions. Methods This study meticulously constructed a comprehensive database through systematic computerized searches conducted on PubMed, Embase, CNKI, Wanfang, VIP, and CBM up to May 2022. The inclusion criteria encompassed randomized controlled trials (RCTs) published in either Chinese or English, focusing on the therapeutic applications of SPGs for various medical conditions. Both qualitative and quantitative outcome indicators were considered eligible for inclusion. Results This comprehensive study reviewed 36 publications, comprising 10 high-quality, 23 medium-quality, and three low-quality articles. The study investigated various diseases, including allergic rhinitis (AR), ischemic strokes (IS), cluster headache (CH), primary trigeminal neuralgia (PTN), pediatric chronic secretory otitis (PCSO), refractory facial paralysis (RFP), chronic tension-type headache (CTTH), as well as the analysis of low-frequency sphenopalatine ganglion stimulation (LF-SPGs) in chronic cluster headache (CCH) and the impact of SPGs on Normal nasal cavity function (NNCF). SPGs demonstrate efficacy in the treatment of AR. Regarding the improvement of rhinoconjunctivitis quality of life questionnaire (RQLQ) scores, SPGs are considered the optimal intervention according to the SUCRA ranking. Concerning the improvement in Total Nasal Symptom Score (TNSS), Conventional Acupuncture Combined with Tradiational Chinese Medicine (CA-TCM) holds a significant advantage in the SUCRA ranking and is deemed the best intervention. In terms of increasing Effective Rate (ER), SPGs outperformed both conventional acupuncture (CA) and Western Medicine (WM; P < 0.05). In the context of SPGs treatment for IS, the results indicate a significant improvement in the 3-month outcomes, as evaluated by the modified Rankin Scale (mRS) in the context of Cerebral Cortical Infarction (CCI; P < 0.05). In the treatment of CH with SPGs, the treatment has been shown to have a statistically significant effect on the relief and disappearance of headaches (P < 0.05). The impact of SPGs on NNCF reveals statistically significant improvements (P < 0.05) in nasal airway resistance (NAR), nasal cavity volume (NCV), exhaled nitric oxide (eNO), substance P (SP), vasoactive intestinal peptide (VIP) and neuropeptide Y (NPY). SPGs treatments for PCSO, RFP, and CTTH, when compared to control groups, yielded statistically significant results (P < 0.05). Conclusion SPGs demonstrate significant effectiveness in the treatment of AR, IS, and CH. Effective management of CCH may require addressing both autonomic dysregulation and deeper neural pathways. However, additional high-quality research is essential to clarify its effects on NNCF, PTN, PCSO, RFP, and CTTH. Systematic Review Registration PROSPERO, identifier CRD42021252073, https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=312429.
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Affiliation(s)
- Lingli Qin
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Dian Chen
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xian Li
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yue Gao
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Wanying Xia
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Hanxi Dai
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Linjie Qiu
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jinsheng Yang
- Institute of Basic Theory for Chinese Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Lu Zhang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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May A, Evers S, Goadsby PJ, Leone M, Manzoni GC, Pascual J, Carvalho V, Romoli M, Aleksovska K, Pozo-Rosich P, Jensen RH. European Academy of Neurology guidelines on the treatment of cluster headache. Eur J Neurol 2023; 30:2955-2979. [PMID: 37515405 DOI: 10.1111/ene.15956] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 06/22/2023] [Accepted: 06/23/2023] [Indexed: 07/30/2023]
Abstract
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.
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Affiliation(s)
- Arne May
- Department of Systems Neuroscience, University Medical Center Hamburg- Eppendorf, Hamburg, Germany
| | - Stefan Evers
- Department of Neurology, Lindenbrunn Hospital, Coppenbrügge, Germany
- Faculty of Medicine, University of Münster, Münster, Germany
| | - Peter J Goadsby
- NIHR King's CRF, SLaM Biomedical Research Centre, King's College London, London, UK
| | - Massimo Leone
- Neuroalgology Department, Foundation of the Carlo Besta Neurological Institute, IRCCS, Milan, Italy
| | | | - Julio Pascual
- Service of Neurology, University Hospital Marqués de Valdecilla, Universidad de Cantabria and IDIVAL, Santander, Spain
| | - Vanessa Carvalho
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
- Centro de Estudos Egas Moniz, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Michele Romoli
- Neurology and Stroke Unit, Bufalini Hospital, Cesena, Italy
| | | | - Patricia Pozo-Rosich
- Headache Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Headache Research Group, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Rigmor H Jensen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, University of Copenhagen, Copenhagen, Denmark
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Diener HC, Tassorelli C, Dodick DW. Management of Trigeminal Autonomic Cephalalgias Including Chronic Cluster: A Review. JAMA Neurol 2023; 80:308-319. [PMID: 36648786 DOI: 10.1001/jamaneurol.2022.4804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Importance Trigeminal autonomic cephalalgias (TACs) comprise a unique collection of primary headache disorders characterized by moderate or severe unilateral pain, localized in in the area of distribution of the first branch of the trigeminal nerve, accompanied by cranial autonomic symptoms and signs. Most TACs are rare diseases, which hampers the possibility of performing randomized clinical trials and large studies. Therefore, knowledge of treatment efficacy must be based only on observational studies, rare disease registries, and case reports, where real-world data and evidence play an important role in health care decisions. Observations Chronic cluster headache is the most common of these disorders, and the literature offers some evidence from randomized clinical trials to support the use of pharmacologic and neurostimulation treatments. Galcanezumab, a monoclonal antibody targeting the calcitonin gene-related peptide, was not effective at 3 months in a randomized clinical trial but showed efficacy at 12 months in a large case series. For the other TACs (ie, paroxysmal hemicrania, hemicrania continua, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing, and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms), only case reports and case series are available to guide physicians in everyday management. Conclusions and Relevance The accumulation of epidemiologic, pathophysiologic, natural history knowledge, and data from case series and small controlled trials, especially over the past 20 years from investigators around the world, has added to the previously limited evidence and has helped advance and inform the treatment approach to rare TACs, which can be extremely challenging for clinicians.
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Affiliation(s)
- Hans Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology (IMIBE), Department of Neuroepidemiology, University Duisburg-Essen, Essen, Germany
| | - Cristina Tassorelli
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Headache Science & Neurorehabilitation Centre, IRCCS C., Mondino Foundation, Pavia, Italy
| | - David W Dodick
- Department of Neurology, Mayo Clinic, Phoenix, Arizona
- Atria Institute, New York, New York
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Neuromodulation in headache and craniofacial neuralgia: Guidelines from the Spanish Society of Neurology and the Spanish Society of Neurosurgery. NEUROLOGÍA (ENGLISH EDITION) 2021. [DOI: 10.1016/j.nrleng.2020.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Siakallis L, Connor SEJ. Response to Letter to the Editor Regarding: "Localization of the Sphenopalatine Ganglion Within the Pterygopalatine Fossa on Computed Tomography Angiography-A Potential Role in the Setting of Sphenopalatine Ganglion Microstimulator Implantation". Neuromodulation 2020; 23:1050-1051. [PMID: 32969102 DOI: 10.1111/ner.13270] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Loizos Siakallis
- Department of Neuroradiology, King's College Hospital, London, UK
| | - Steve E J Connor
- Department of Neuroradiology, King's College Hospital, London, UK.,School of Biomedical Engineering & Imaging Sciences Clinical Academic Group, King's College London, London, UK.,Department of Radiology, Guy's and St Thomas' Hospital, London, UK
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Belvís R, Irimia P, Seijo-Fernández F, Paz J, García-March G, Santos-Lasaosa S, Latorre G, González-Oria C, Rodríguez R, Pozo-Rosich P, Láinez JM. Neuromodulation in headache and craniofacial neuralgia: guidelines from the Spanish Society of Neurology and the Spanish Society of Neurosurgery. Neurologia 2020; 36:61-79. [PMID: 32718873 DOI: 10.1016/j.nrl.2020.04.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/11/2020] [Accepted: 04/15/2020] [Indexed: 01/01/2023] Open
Abstract
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.
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Affiliation(s)
- R Belvís
- Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - P Irimia
- Clínica Universitaria de Navarra, Pamplona, España.
| | | | - J Paz
- Hospital Universitario La Paz, Madrid, España
| | | | | | - G Latorre
- Hospital Universitario de Fuenlabrada, Madrid, España
| | | | - R Rodríguez
- Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | | | - J M Láinez
- Hospital Clínico Universitario, Valencia, España
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Schmerzärzte dürfen nicht wegsehen: Was passiert bei Ausfall eines Medizinprodukteherstellers? Schmerz 2020; 34:282-284. [DOI: 10.1007/s00482-020-00470-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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8
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Siakallis L, Connor SEJ. Localization of the Sphenopalatine Ganglion Within the Pterygopalatine Fossa on Computed Tomography Angiography-A Potential Role in the Setting of Sphenopalatine Ganglion Microstimulator Implantation. Neuromodulation 2020; 24:1422-1428. [PMID: 32383279 DOI: 10.1111/ner.13170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 03/17/2020] [Accepted: 04/14/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES A recent approach to treatment of cluster headaches (CH) employs a microstimulator device for on-demand neuromodulation of the sphenopalatine ganglion (SPG) during an acute CH attack. A precise anatomical localization of the SPG within the pterygopalatine fossa (PPF) is optimal in order to position the SPG electrode array. This study aims to investigate a novel approach for SPG localization using computed tomography angiographic studies (CTA). MATERIALS AND METHODS Two independent observers identified the location of the SPG on 54 computed tomography angiographic studies (CTA) and measured its position relative to the vidian canal (VC). The qualitative confidence of identification, morphology, position within the PPF and its relation to vascular structures were also recorded. RESULTS The SPG was detectable in 88% of cases with a variable position. The most frequent positions were superior (56%) and lateral (99%) relative to the VC with a mean (±SD) craniocaudal distance of 0.34 mm (±1.38) and a mean mediolateral distance of 3.04 mm (±1.2). However, in a considerable proportion of cases, the SPG was identified inferiorly to the VC (33%). Interobserver and intraobserver agreement for SPG location were moderate and strong respectively. CONCLUSIONS Since localization of SPG on CTAs is feasible and reproducible, it has future clinical potential to aid placement, optimal positioning and individualized programming of the electrode array.
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Affiliation(s)
- Loizos Siakallis
- Department of Neuroradiology, King's College Hospital, London, England, UK
| | - Steve E J Connor
- Department of Neuroradiology, King's College Hospital, London, England, UK.,School of Biomedical Engineering & Imaging Sciences Clinical Academic Group, King's College London, London, England, UK.,Department of Radiology, Guy's and St Thomas' Hospital, London, England, UK
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9
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The need for continued care after sponsor closure. Lancet Neurol 2020; 19:205. [DOI: 10.1016/s1474-4422(20)30023-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 01/10/2020] [Indexed: 11/23/2022]
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10
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Rajneesh K. Occipital Nerve Stimulation and Sphenopalatine Ganglion Stimulation for Treatment of Intractable Headache Syndromes. Neurol India 2020; 68:S231-S234. [DOI: 10.4103/0028-3886.302477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Liu SC, Kao MC, Huang YC, Su WF. Vidian Neurectomy for Management of Chronic Cluster Headache. Neurosurgery 2019; 84:1059-1064. [PMID: 30535031 DOI: 10.1093/neuros/nyy136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 03/19/2018] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Shao-Cheng Liu
- Department of Otolaryngology-Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Ming-Chang Kao
- Division of Pain Medicine, Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan, Republic of China.,School of Medicine, Tzu Chi University, Hualien, Taiwan, Republic of China
| | - Yun-Chen Huang
- School of Medicine, Tzu Chi University, Hualien, Taiwan, Republic of China.,Department of Otolaryngology-Head and Neck Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan, Republic of China
| | - Wan-Fu Su
- School of Medicine, Tzu Chi University, Hualien, Taiwan, Republic of China.,Department of Otolaryngology-Head and Neck Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan, Republic of China
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Topical Sphenopalatine Ganglion Block Compared With Epidural Blood Patch for Postdural Puncture Headache Management in Postpartum Patients: A Retrospective Review. Reg Anesth Pain Med 2019; 43:880-884. [PMID: 30063655 DOI: 10.1097/aap.0000000000000840] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES Postdural puncture headache (PDPH) is a severe and debilitating complication of unintentional dural puncture. The criterion-standard treatment for PDPH has been epidural blood patch (EBP), but it is an invasive intervention with the potential for severe complications, such as meningitis and paralysis. We believe this is the first ever 17-year retrospective chart review in which we compare the effectiveness of sphenopalatine ganglion block (SPGB) to EBP for PDPH treatment in postpartum patients. METHODS We conducted a chart review of the first authors' obstetric patients who experienced PDPH from an unintentional dural puncture from a 17-gauge Tuohy needle for labor epidural from January 1997 to July 2014. Demographic characteristics, headache severity, and associated symptoms were collected prior to treatment. Forty-two patients who received SPGB and 39 patients who received EBP were identified. Residual headache, recovery from associated symptoms, and new treatment complications were compared between the 2 groups at 30 minutes, 1 hour, 24 hours, 48 hours, and 1 week posttreatment. RESULTS A greater number of patients showed significant relief in their PDPH and associated symptoms at 30 and 60 minutes after treatment with SPGB than after treatment with EBP (P < 0.01). Only the EBP patients complained of posttreatment complications, which all resolved in 48 hours. CONCLUSIONS A greater number of patients experienced a quicker onset of headache relief, without any new complications, from treatment with SPGB versus EBP. We believe that SPGB is a safe, inexpensive, and well-tolerated treatment. We hope that clinical trials will be conducted in the future that will confirm our findings and allow us to recommend SPGB for PDPH treatment prior to offering patients EBP.
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Vukovic Cvetkovic V, Jensen RH. Neurostimulation for the treatment of chronic migraine and cluster headache. Acta Neurol Scand 2019; 139:4-17. [PMID: 30291633 DOI: 10.1111/ane.13034] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 09/17/2018] [Accepted: 10/02/2018] [Indexed: 12/17/2022]
Abstract
Small subsets of patients who fail to respond to pharmacological treatment may benefit from alternative treatment methods. In the last decade, neurostimulation is being explored as a potential treatment option for the patients with chronic, severely disabling refractory primary headaches. To alleviate pain, specific nerves and brain areas have been stimulated, and various methods have been explored: deep brain stimulation, occipital nerve stimulation, and sphenopalatine ganglion stimulation are among the more invasive ones, whereas transcranial magnetic stimulation and supraorbital nerve stimulation are noninvasive. Vagal nerve stimulation can be invasive or noninvasive, though this review included only data for noninvasive VNS. Most of these methods have been tested in small open-label patient series; recently, more data from randomized, controlled, and blinded studies are available. Although neurostimulation treatments have demonstrated good efficacy in many studies, it still has not been established as a standard treatment in refractory patients. This review analyzes the available evidence regarding efficacy and safety of different neurostimulation modalities for the treatment of chronic migraine and cluster headache.
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Levin D, Cohen S, Mellender S, Kiss G. Sphenopalatine Ganglion Block Successfully Treats Migraines in a Type 1 Arnold Chiari Malformation Pregnant Patient: A Case Report. A A Pract 2018; 11:32-34. [DOI: 10.1213/xaa.0000000000000722] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Pietzsch JB, Weber SA, Lund N, Gaul C. Changes in medication cost observed in chronic cluster headache patients treated with sphenopalatine ganglion (SPG) stimulation: Analysis based on 1-year data from the Pathway R-1 Registry. Cephalalgia 2018; 38:1455-1462. [PMID: 29921140 DOI: 10.1177/0333102418784689] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background On-demand stimulation of the sphenopalatine ganglion (SPG) by means of an implantable neurostimulation system has been shown to be a safe and effective therapy for treatment-refractory cluster headache patients. Our objective was to estimate changes in cluster headache medication cost observed in SPG-treated chronic patients. Methods Detailed patient-level data of 71 chronic patients treated with the Pulsante® SPG Microstimulator System were available from the Pathway R-1 Registry through 12 months' follow-up. We used utilization data of preventive and acute medications reported at baseline, 3, 6, 9, and 12 months to estimate annualized drug costs for SPG-treated patients and compared it to baseline. Cost estimates for all drug/dosage combinations were developed based on German medication prices for 2016. Results In the base case analysis, mean annual acute and preventive medication costs decreased from €14,178 to €6924 (-€7254; -51%), and €559 to €328 (-€231; -41%), respectively, leading to total estimated annual drug cost savings of €7484, 97% of which were attributable to acute medications. Conclusions Our analysis suggests that SPG stimulation for the treatment of chronic cluster headache is associated with pronounced reductions in cluster headache medication usage that might lead to sizable annual savings in medication costs.
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Affiliation(s)
| | | | - Nunu Lund
- 3 University of Copenhagen, Copenhagen, Denmark
| | - Charly Gaul
- 4 Migraine and Headache Clinic Königstein, Königstein im Taunus, Germany
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Lee SH, Kim Y, Lim TY. Efficacy of sphenopalatine ganglion block in nasal mucosal headache presenting as facial pain. Cranio 2018; 38:128-130. [DOI: 10.1080/08869634.2018.1475859] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Sung Hyun Lee
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Youngdeuk Kim
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Young Lim
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abstract
Cluster headache is characterized by severe, unilateral headache attacks of orbital, supraorbital or temporal pain lasting 15-180 min accompanied by ipsilateral lacrimation, rhinorrhea and other cranial autonomic manifestations. Cluster headache attacks need fast-acting abortive agents because the pain peaks very quickly; sumatriptan injection is the gold standard acute treatment. First-line preventative drugs include verapamil and carbolithium. Other drugs demonstrated effective in open trials include topiramate, valproic acid, gabapentin and others. Steroids are very effective; local injection in the occipital area is also effective but its prolonged use needs caution. Monoclonal antibodies against calcitonin gene-related peptide are under investigation as prophylactic agents in both episodic and chronic cluster headache. A number of neurostimulation procedures including occipital nerve stimulation, vagus nerve stimulation, sphenopalatine ganglion stimulation and the more invasive hypothalamic stimulation are employed in chronic intractable cluster headache.
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Abstract
Cluster headache is an excruciating, strictly one-sided pain syndrome with attacks that last between 15 minutes and 180 minutes and that are accompanied by marked ipsilateral cranial autonomic symptoms, such as lacrimation and conjunctival injection. The pain is so severe that female patients describe each attack as worse than childbirth. The past decade has seen remarkable progress in the understanding of the pathophysiological background of cluster headache and has implicated the brain, particularly the hypothalamus, as the generator of both the pain and the autonomic symptoms. Anatomical connections between the hypothalamus and the trigeminovascular system, as well as the parasympathetic nervous system, have also been implicated in cluster headache pathophysiology. The diagnosis of cluster headache involves excluding other primary headaches and secondary headaches and is based primarily on the patient's symptoms. Remarkable progress has been achieved in developing effective treatment options for single cluster attacks and in developing preventive measures, which include pharmacological therapies and neuromodulation.
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Affiliation(s)
- Arne May
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany
| | | | - Delphine Magis
- University Department of Neurology CHR, CHU de Liege, Belgium
| | - Patricia Pozo-Rosich
- Headache and Craniofacial Pain Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Headache Research Group, VHIR, Universitat Autònoma Barcelona, Barcelona, Spain
| | - Stefan Evers
- Department of Neurology, Krankenhaus Lindenbrunn, Coppenbrügge, Germany
| | - Shuu-Jiun Wang
- Taipei Veterans General Hospital, National Yang-Ming University School of Medicine, Taipei, Taiwan
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Barloese M, Petersen A, Stude P, Jürgens T, Jensen RH, May A. Sphenopalatine ganglion stimulation for cluster headache, results from a large, open-label European registry. J Headache Pain 2018; 19:6. [PMID: 29349561 PMCID: PMC5773459 DOI: 10.1186/s10194-017-0828-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 12/18/2017] [Indexed: 01/03/2023] Open
Abstract
Background Cluster headache (CH) is a disabling primary headache disorder characterized by severe periorbital pain. A subset of patients does not respond to established pharmacological therapy. This study examines outcomes of a cohort of mainly chronic CH patients treated with sphenopalatine ganglion (SPG) stimulation. Methods Patients were followed in an open-label prospective study for 12 months. Ninety-seven CH patients (88 chronic, 9 episodic) underwent trans-oral insertion of a microstimulator targeting the SPG. Patients recorded stimulation effect prospectively for individual attacks. Frequency, use of preventive and acute medications, headache impact (HIT-6) and quality of life measures (SF-36v2) were monitored at clinic visits. Per protocol, frequency responders experienced ≥ 50% reduction in attack frequency and acute responders treated ≥ 50% of attacks. HIT-6 responders experienced an improvement ≥ 2.3 units and SF-36 responders ≥ 4 units vs. baseline. Results Eighty-five patients (78 chronic, 7 episodic) remained implanted and were evaluated for effectiveness at 12 months. In total, 68% of all patients were responders, 55% of chronic patients were frequency responders and 32% of all patients were acute responders. 67% of patients using acute treatments were able to reduce the use of these by 52% and 74% of chronic patients were able to stop, reduce or remain off all preventive medications. 59% of all patients were HIT-6 responders, 67% were SF-36 responders. Conclusions This open-label registry corroborates that SPG stimulation is an effective therapy for CH patients providing therapeutic benefits and improvements in use of medication as well as headache impact and quality of life. Electronic supplementary material The online version of this article (10.1186/s10194-017-0828-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mads Barloese
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet-Glostrup, Nordre Ringvej 57, 2600, Glostrup, Denmark. .,Danish Headache Centre, Department of Neurology, Rigshospitalet-Glostrup, Nordre Ringvej 57, 2600, Glostrup, Denmark.
| | - Anja Petersen
- Danish Headache Centre, Department of Neurology, Rigshospitalet-Glostrup, Nordre Ringvej 57, 2600, Glostrup, Denmark
| | - Philipp Stude
- Schmerztherapie, Geriatrie und Palliativmedizin, Bochum, Kurt-Schumacher-Platz, 11-12 44787, Bochum, Germany
| | - Tim Jürgens
- Department of Neurology, University Medical Center Rostock, Gehlsherimer Str. 20, 18147, Rostock, Germany
| | - Rigmor Højland Jensen
- Danish Headache Centre, Department of Neurology, Rigshospitalet-Glostrup, Nordre Ringvej 57, 2600, Glostrup, Denmark
| | - Arne May
- Department of Systems Neuroscience, Universitäts-Klinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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Triantafyllidi H, Arvaniti C, Schoinas A, Benas D, Vlachos S, Palaiodimos L, Pavlidis G, Ikonomidis I, Batistaki C, Voumvourakis C, Lekakis J. Bilateral sphenopalatine ganglion block reduces blood pressure in never treated patients with essential hypertension. A randomized controlled single-blinded study. Int J Cardiol 2018; 250:233-239. [DOI: 10.1016/j.ijcard.2017.10.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 10/04/2017] [Accepted: 10/11/2017] [Indexed: 01/21/2023]
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Lambru G, Andreou AP, de la Torre ER, Martelletti P. Tackling the perils of unawareness: the cluster headache case. J Headache Pain 2017; 18:49. [PMID: 28451865 PMCID: PMC5407400 DOI: 10.1186/s10194-017-0757-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 04/21/2017] [Indexed: 01/03/2023] Open
Affiliation(s)
- Giorgio Lambru
- Headache Centre, Guy's and St Thomas' NHS Trust, London, UK
| | - Anna P Andreou
- Headache Centre, Guy's and St Thomas' NHS Trust, London, UK.,Headache Research - Wolfson CARD, King's College London, London, UK
| | | | - Paolo Martelletti
- Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy. .,Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy. .,European Headache Federation, London, UK.
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Akerman S, Romero-Reyes M, Holland PR. Current and novel insights into the neurophysiology of migraine and its implications for therapeutics. Pharmacol Ther 2017; 172:151-170. [PMID: 27919795 DOI: 10.1016/j.pharmthera.2016.12.005] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Migraine headache and its associated symptoms have plagued humans for two millennia. It is manifest throughout the world, and affects more than 1/6 of the global population. It is the most common brain disorder, and is characterized by moderate to severe unilateral headache that is accompanied by vomiting, nausea, photophobia, phonophobia, and other hypersensitive symptoms of the senses. While there is still a clear lack of understanding of its neurophysiology, it is beginning to be understood, and it seems to suggest migraine is a disorder of brain sensory processing, characterized by a generalized neuronal hyperexcitability. The complex symptomatology of migraine indicates that multiple neuronal systems are involved, including brainstem and diencephalic systems, which function abnormally, resulting in premonitory symptoms, ultimately evolving to affect the dural trigeminovascular system, and the pain phase of migraine. The migraineur also seems to be particularly sensitive to fluctuations in homeostasis, such as sleep, feeding and stress, reflecting the abnormality of functioning in these brainstem and diencephalic systems. Implications for therapeutic development have grown out of our understanding of migraine neurophysiology, leading to major drug classes, such as triptans, calcitonin gene-related peptide receptor antagonists, and 5-HT1F receptor agonists, as well as neuromodulatory approaches, with the promise of more to come. The present review will discuss the current understanding of the neurophysiology of migraine, particularly migraine headache, and novel insights into the complex neural networks responsible for associated neurological symptoms, and how interaction of these networks with migraine pain pathways has implications for the development of novel therapeutics.
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Affiliation(s)
- Simon Akerman
- Department of Oral and Maxillofacial Pathology, Radiology and Medicine, New York University College of Dentistry, New York, NY 10010, USA.
| | - Marcela Romero-Reyes
- Department of Oral and Maxillofacial Pathology, Radiology and Medicine, New York University College of Dentistry, New York, NY 10010, USA
| | - Philip R Holland
- Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Abstract
PURPOSE OF REVIEW Chronic headache sufferers are estimated to be around 3% of the population. These patients have a high disease burden. When prophylactic treatments have low efficacy and tolerability, patients are in need of alternative therapeutic strategies and options. RECENT FINDINGS In the last decade, a number of neuromodulation procedures have been introduced as treatment of chronic intractable headache patients when pharmacological treatments fail or are not well tolerated. Neurostimulation of peripheral and central nervous system has been carried out, and now, various non-invasive and invasive stimulation devices are available. Non-invasive neurostimulation options include vagus nerve stimulation, supraorbital stimulation and single-pulse transcranial magnetic stimulation; invasive procedures include occipital nerve stimulation, sphenopalatine ganglion stimulation and hypothalamic deep brain stimulation. In many cases, results supporting their use derive from open-label series and small controlled trial studies. Lack of adequate placebo hampers adequate randomized controlled trials. In this paper, we give an overview on the main neurostimulation procedures in terms of results and putative mechanism of cation.
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Improved surgical procedure using intraoperative navigation for the implantation of the SPG microstimulator in patients with chronic cluster headache. Int J Comput Assist Radiol Surg 2017; 12:2119-2128. [DOI: 10.1007/s11548-016-1512-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 12/09/2016] [Indexed: 01/03/2023]
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Barloese MCJ, Jürgens TP, May A, Lainez JM, Schoenen J, Gaul C, Goodman AM, Caparso A, Jensen RH. Cluster headache attack remission with sphenopalatine ganglion stimulation: experiences in chronic cluster headache patients through 24 months. J Headache Pain 2016; 17:67. [PMID: 27461394 PMCID: PMC4961666 DOI: 10.1186/s10194-016-0658-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 07/01/2016] [Indexed: 01/03/2023] Open
Abstract
Background Cluster headache (CH) is a debilitating headache disorder with severe consequences for patient quality of life. On-demand neuromodulation targeting the sphenopalatine ganglion (SPG) is effective in treating the acute pain and a subgroup of patients experience a decreased frequency of CH attacks. Methods We monitored self-reported attack frequency, headache disability, and medication intake in 33 patients with medically refractory, chronic CH (CCH) in an open label follow-up study of the original Pathway CH-1 study. Patients were followed for at least 24 months (average 750 ± 34 days, range 699-847) after insertion of an SPG microstimulator. Remission periods (attack-free periods exceeding one month, per the ICHD 3 (beta) definition) occurring during the 24-month study period were characterized. Attack frequency, acute effectiveness, medication usage, and questionnaire data were collected at regular clinic visits. The time point “after remission” was defined as the first visit after the end of the remission period. Results Thirty percent (10/33) of enrolled patients experienced at least one period of complete attack remission. All remission periods followed the start of SPG stimulation, with the first period beginning 134 ± 86 (range 21-272) days after initiation of stimulation. On average, each patient’s longest remission period lasted 149 ± 97 (range 62-322) days. The ability to treat acute attacks before and after remission was similar (37 % ± 25 % before, 49 % ± 32 % after; p = 0.2188). Post-remission headache disability (HIT-6) was significantly improved versus baseline (67.7 ± 6.0 before, 55.2 ± 11.4 after; p = 0.0118). Six of the 10 remission patients experienced clinical improvements in their preventive medication use. At 24 months post insertion headache disability improvements remained and patient satisfaction measures were positive in 100 % (10/10). Conclusions In this population of 33 refractory CCH patients, in addition to providing the ability to treat acute attacks, neuromodulation of the SPG induced periods of remission from cluster attacks in a subset of these. Some patients experiencing remission were also able to reduce or stop their preventive medication and remissions were accompanied by an improvement in headache disability.
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Affiliation(s)
- Mads C J Barloese
- Danish Headache Centre, Department of Neurology, Rigshospitalet-Glostrup, University of Copenhagen, Copenhagen, Denmark. .,Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet-Glostrup, Copenhagen, Denmark.
| | - Tim P Jürgens
- Department of Neurology, University Medical Center Rostock, Rostock, Germany.,Department of Systems Neuroscience, University Medical-Center Hamburg-Eppendorf, Hamburg, Germany
| | - Arne May
- Department of Systems Neuroscience, University Medical-Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jose Miguel Lainez
- Department of Neurology, Hospital Clinico Universitario, Universidad Católica de Valencia, Valencia, Spain
| | - Jean Schoenen
- Headache Research Unit. Department of Neurology - CHR Citadelle, Liège University, Liège, Belgium
| | - Charly Gaul
- Migraine- and Headache Clinic Königstein, Königstein, Germany
| | - Amy M Goodman
- Clinical Research, Autonomic Technologies, Redwood City, California, USA
| | - Anthony Caparso
- Clinical Research, Autonomic Technologies, Redwood City, California, USA
| | - Rigmor Højland Jensen
- Danish Headache Centre, Department of Neurology, Rigshospitalet-Glostrup, University of Copenhagen, Copenhagen, Denmark
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Láinez MJ, Marti AS. Sphenopalatine ganglion stimulation in cluster headache and other types of headache. Cephalalgia 2016; 36:1149-1155. [PMID: 27152017 DOI: 10.1177/0333102416644968] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives The cluster headache is the most excruciatingly painful primary headache. In some patients, neither preventive treatment nor acute treatment is effective or treatment is poorly tolerated. The sphenopalatine ganglion (SPG) has an important role in the pathophysiology of cluster headache and, for this reason, SPG stimulation has been used to treat cluster headache. Methods We have reviewed the published literature on the role of the SPG in cluster headache and the use of different treatments targeting the SPG. Results Multiple procedures have been used over the SPG to treat pain and trigemino-autonomic symptoms in patients with refractory cluster headache. After obtaining good results in a small number of patients, a miniaturized stimulator was developed. Stimulation of the SPG with this device proved to be efficacious in acute and preventive treatment in a clinical trial involving patients with chronic refractory cluster headache. Implantation of the device is minimally invasive and the most frequent side-effects are mild, such as paraesthesia and pain over the maxillary area. In patients who have used the SPG device for longer than one year, the therapeutic effect remains effective and the side-effects decrease. Conclusions The reported studies have demonstrated that SPG stimulation is a safe and effective treatment for chronic cluster headache. Long-term studies have shown that the effect remains over time and this treatment could be a good choice in patients with chronic refractory headache. We need more data about its potential use in other forms of headache, such as other trigemino-autonomic headaches or migraine.
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Affiliation(s)
- Miguel Ja Láinez
- 1 Department of Neurology, Hospital Clínico Universitario Valencia, Spain.,2 Department of Neurology, Universidad Católica de Valencia, Spain
| | - Ana Suller Marti
- 1 Department of Neurology, Hospital Clínico Universitario Valencia, Spain
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Jürgens TP, Barloese M, May A, Láinez JM, Schoenen J, Gaul C, Goodman AM, Caparso A, Jensen RH. Long-term effectiveness of sphenopalatine ganglion stimulation for cluster headache. Cephalalgia 2016; 37:423-434. [PMID: 27165493 PMCID: PMC5405839 DOI: 10.1177/0333102416649092] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objectives The sphenopalatine ganglion (SPG) plays a pivotal role in cluster headache (CH) pathophysiology as the major efferent parasympathetic relay. We evaluated the long-term effectiveness of SPG stimulation in medically refractory, chronic CH patients. Methods Thirty-three patients were enrolled in an open-label follow-up study of the original Pathway CH-1 study, and participated through 24 months post-insertion of a microstimulator. Response to therapy was defined as acute effectiveness in ≥ 50% of attacks or a ≥ 50% reduction in attack frequency versus baseline. Results In total, 5956 attacks (180.5 ± 344.8, range 2–1581 per patient) were evaluated. At 24 months, 45% (n = 15) of patients were acute responders. Among acute responders, a total of 4340 attacks had been treated, and in 78% of these, effective therapy was achieved using only SPG stimulation (relief from moderate or greater pain or freedom from mild pain or greater). A frequency response was observed in 33% (n = 11) of patients with a mean reduction of attack frequency of 83% versus baseline. In total, 61% (20/33) of all patients were either acute or frequency responders or both. The majority maintained their therapeutic response through the 24-month evaluation. Conclusions In the population of disabled, medically refractory chronic CH patients treated in this study, SPG stimulation is an effective acute therapy in 45% of patients, offering sustained effectiveness over 24 months of observation. In addition, a maintained, clinically relevant reduction of attack frequency was observed in a third of patients. These long-term data provide support for the use of SPG stimulation for disabled patients and should be considered after medical treatments fail, are not tolerated or are inconvenient for the patients.
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Affiliation(s)
- Tim P Jürgens
- 1 Department of Systems Neuroscience, Universitäts-Klinikum Hamburg-Eppendorf, Hamburg, Germany.,2 Department of Neurology, University Medical Center Rostock, Rostock, Germany
| | - Mads Barloese
- 3 Department of Clinical Physiology, Nuclear Medicine and Pet, Rigshospitalet-Glostrup, Copenhagen, Denmark
| | - Arne May
- 1 Department of Systems Neuroscience, Universitäts-Klinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Jose Miguel Láinez
- 4 Department of Neurology, Hospital Clinico Universitario, Universidad Católica de Valencia, Valencia, Spain
| | - Jean Schoenen
- 5 Headache Research Unit, Department of Neurology - CHR Citadelle, Liège University, Liège, Belgium
| | - Charly Gaul
- 6 Migraine and Headache Clinic Königstein, Königstein, Germany
| | - Amy M Goodman
- 7 Clinical Research, Autonomic Technologies, Inc., Redwood City, CA, USA
| | - Anthony Caparso
- 7 Clinical Research, Autonomic Technologies, Inc., Redwood City, CA, USA
| | - Rigmor Højland Jensen
- 8 Danish Headache Centre, Department of Neurology, Rigshospitalet-Glostrup, University of Copenhagen, Copenhagen, Denmark
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31
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Miller S, Sinclair AJ, Davies B, Matharu M. Neurostimulation in the treatment of primary headaches. Pract Neurol 2016; 16:362-75. [PMID: 27152027 PMCID: PMC5036247 DOI: 10.1136/practneurol-2015-001298] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2016] [Indexed: 11/18/2022]
Abstract
There is increasing interest in using neurostimulation to treat headache disorders. There are now several non-invasive and invasive stimulation devices available with some open-label series and small controlled trial studies that support their use. Non-invasive stimulation options include supraorbital stimulation (Cefaly), vagus nerve stimulation (gammaCore) and single-pulse transcranial magnetic stimulation (SpringTMS). Invasive procedures include occipital nerve stimulation, sphenopalatine ganglion stimulation and ventral tegmental area deep brain stimulation. These stimulation devices may find a place in the treatment pathway of headache disorders. Here, we explore the basic principles of neurostimulation for headache and overview the available methods of neurostimulation.
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Affiliation(s)
- Sarah Miller
- Headache Group, Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK
| | - Alex J Sinclair
- Neurometabolism, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, The University of Birmingham, Birmingham, UK
| | - Brendan Davies
- Department of Neurology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Manjit Matharu
- Headache Group, Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK
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Androulakis XM, Krebs KA, Ashkenazi A. Hemicrania continua may respond to repetitive sphenopalatine ganglion block: A case report. Headache 2016; 56:573-9. [PMID: 26926875 DOI: 10.1111/head.12783] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 10/22/2015] [Accepted: 10/23/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND Hemicrania continua (HC) is a chronic headache disorder characterized by a continuous, strictly unilateral head pain accompanied by cranial autonomic symptoms, which completely responds to indomethacin; however, few alternative treatment options exist for the patients with this disorder who cannot tolerate indomethacin. Sphenopalatine ganglion (SPG) block has been used for the treatment of various headaches, with the strongest evidence for efficacy in cluster headache. CASE REPORT A 52-year-old woman with a 7-year history of HC was evaluated in our clinic for management of her headaches after she had stopped using indomethacin due to a bleeding gastrointestinal ulcer. After failing multiple pharmacologic therapies, she was treated with repetitive SPG blocks using bupivacaine (0.6 mL at 0.5%) twice a week for 6 weeks and followed by maintenance therapy. This treatment protocol resulted in significant improvement in her headaches, mood, and functional capacity. CONCLUSION SPG block using a local anesthetic may be an effective treatment for patients with HC, specifically for those who cannot tolerate indomethacin, or when this drug is contraindicated.
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Affiliation(s)
- X Michelle Androulakis
- School of Medicine, Department of Neurology, University of South Carolina, Columbia, SC, USA
| | - Kaitlin A Krebs
- School of Medicine, Department of Neurology, University of South Carolina, Columbia, SC, USA
| | - Avi Ashkenazi
- Department of Medicine (Neurology), Doylestown Hospital, Doylestown, PA, USA
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Robbins MS, Robertson CE, Kaplan E, Ailani J, Charleston L, Kuruvilla D, Blumenfeld A, Berliner R, Rosen NL, Duarte R, Vidwan J, Halker RB, Gill N, Ashkenazi A. The Sphenopalatine Ganglion: Anatomy, Pathophysiology, and Therapeutic Targeting in Headache. Headache 2015; 56:240-58. [DOI: 10.1111/head.12729] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Revised: 10/15/2015] [Accepted: 10/15/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Matthew S. Robbins
- Montefiore Headache Center; Bronx NY USA
- Department of Neurology; Montefiore Medical Center, Albert Einstein College of Medicine; Bronx NY USA
| | | | - Eugene Kaplan
- The Kaplan Headache Center, Optimum Health Medical Group, PLLC; Clifton Park NY USA
| | - Jessica Ailani
- Department of Neurology; Medstar Georgetown University Medical Center; Washington DC USA
| | - Larry Charleston
- Department of Neurology; University of Michigan Health System; Ann Arbor MI USA
| | - Deena Kuruvilla
- Department of Neurology; Yale School of Medicine; New Haven CT USA
| | | | - Randall Berliner
- Department of Neurology; Montefiore Medical Center, Albert Einstein College of Medicine; Bronx NY USA
| | - Noah L. Rosen
- Pain and Headache Center, Cushing Neuroscience Institute, Department of Neurology, Hofstra North Shore LIJ Medical Center; Manhasset NY USA
| | - Robert Duarte
- Pain and Headache Center, Cushing Neuroscience Institute, Department of Neurology, Hofstra North Shore LIJ Medical Center; Manhasset NY USA
| | | | | | | | - Avi Ashkenazi
- Department of Medicine (Neurology); Doylestown Hospital; Doylestown PA USA
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Assaf AT, Hillerup S, Rostgaard J, Puche M, Blessmann M, Kohlmeier C, Pohlenz P, Klatt JC, Heiland M, Caparso A, Papay F. Technical and surgical aspects of the sphenopalatine ganglion (SPG) microstimulator insertion procedure. Int J Oral Maxillofac Surg 2015; 45:245-54. [PMID: 26559753 DOI: 10.1016/j.ijom.2015.09.023] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 08/10/2015] [Accepted: 09/28/2015] [Indexed: 11/26/2022]
Abstract
Cluster headache (CH) is a debilitating, severe form of headache. A novel non-systemic therapy has been developed that produces therapeutic electrical stimulation to the sphenopalatine ganglion (SPG). A transoral surgical technique for inserting the Pulsante SPG Microstimulator into the pterygopalatine fossa (PPF) is presented herein. Technical aspects include detailed descriptions of the preoperative planning using computed tomography or cone beam computed tomography scans for presurgical digital microstimulator insertion into the patient-specific anatomy and intraoperative verification of microstimulator placement. Surgical aspects include techniques to insert the microstimulator into the proper midface location atraumatically. During the Pathway CH-1 and Pathway R-1 studies, 99 CH patients received an SPG microstimulator. Ninety-six had a microstimulator placed within the PPF during their initial procedure. Perioperative surgical sequelae included sensory disturbances, pain, and swelling. Follow-up procedures included placement of a second microstimulator on the opposite side (n=2), adjustment of the microstimulator lead location (n=13), re-placement after initial unsuccessful placement (n=1), and removal (n=5). This SPG microstimulator insertion procedure has sequelae comparable to other oral cavity procedures including tooth extractions, sinus surgery, and dental implant placement. Twenty-five of 29 subjects (86%) completing a self-assessment questionnaire indicated that the surgical effects were tolerable and 90% would make the same decision again.
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Affiliation(s)
- A T Assaf
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - S Hillerup
- Department of Oral and Maxillofacial Surgery, Rigshospitalet and Dental School, University of Copenhagen, Copenhagen, Denmark
| | - J Rostgaard
- Department of Oral and Maxillofacial Surgery, Rigshospitalet and Dental School, University of Copenhagen, Copenhagen, Denmark
| | - M Puche
- Department of Oral and Maxillofacial Surgery, Clinic Hospital, University of Valencia, Valencia, Spain
| | - M Blessmann
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - C Kohlmeier
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - P Pohlenz
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J C Klatt
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - M Heiland
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A Caparso
- Autonomic Technologies, Inc., Redwood City, CA, USA
| | - F Papay
- Institute of Dermatology and Plastic Surgery, Cleveland Clinic, Cleveland, OH, USA
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Charleston L. Do Trigeminal Autonomic Cephalalgias Represent Primary Diagnoses or Points on a Continuum? Curr Pain Headache Rep 2015; 19:22. [DOI: 10.1007/s11916-015-0493-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Assaf AT, Klatt JC, Blessmann M, Kohlmeier C, Friedrich RE, Pohlenz P, May A, Heiland M, Jürgens TP. Value of intra- and post-operative cone beam computed tomography (CBCT) for positioning control of a sphenopalatine ganglion neurostimulator in patients with chronic cluster headache. J Craniomaxillofac Surg 2015; 43:408-13. [PMID: 25648069 DOI: 10.1016/j.jcms.2014.12.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 11/19/2014] [Accepted: 12/29/2014] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION The objective of this study was to determine whether postoperative control of the neurostimulator placement within the pterygopalatine fossa (PPF) by means of 3-dimensional (3D) cone beam computed tomography (CBCT) was of therapeutic relevance compared to intraoperative CBCT imaging alone. MATERIAL AND METHODS Immediately after implantation of the sphenopalatine ganglion (SPG) neurostimulator, intraoperative CBCT datasets were generated in order to visualize the position of the probe within the PPF. Postoperatively, all patients received a CBCT for comparison with intraoperatively acquired radiographs. RESULTS Twenty-four patients with cluster headache (CH) received an SPG neurostimulator. In 4 patients, postoperative CBCT images detected misplacement not found in intraoperative CBCT. In 3 cases, electrode tips were misplaced into the maxillary sinus and in 1 case into the apex of the PPF superior to the suspected location of the SPG. Immediate revision with successful repositioning within 3 days was done in 2 patients and a deferred reimplantation in 1 patient within 6 months. One patient declined revision. CONCLUSION We were able to demonstrate the clinical value of postoperative dental CBCT imaging with a wide region of interest (ROI) due to a superior image quality compared with that achieved with intraoperative medical CBCT. Although intraoperative 3D CBCT imaging of electrode placement is helpful in the acute surgical setting, resolution is, at present, too low to safely exclude misplacement, especially in the maxillary sinus. High-resolution postoperative dental CBCT allows rapid detection and revision of electrode misplacement, thereby avoiding readmission and recurrent tissue trauma.
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Affiliation(s)
- Alexandre T Assaf
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg Eppendorf, University of Hamburg, Martinistr. 52, 20246 Hamburg, Germany.
| | - Jan C Klatt
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg Eppendorf, University of Hamburg, Martinistr. 52, 20246 Hamburg, Germany
| | - Marco Blessmann
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg Eppendorf, University of Hamburg, Martinistr. 52, 20246 Hamburg, Germany
| | - Carsten Kohlmeier
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg Eppendorf, University of Hamburg, Martinistr. 52, 20246 Hamburg, Germany
| | - Reinhard E Friedrich
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg Eppendorf, University of Hamburg, Martinistr. 52, 20246 Hamburg, Germany
| | - Philipp Pohlenz
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg Eppendorf, University of Hamburg, Martinistr. 52, 20246 Hamburg, Germany
| | - Arne May
- Department of Systems Neuroscience, University Medical Center Hamburg Eppendorf, University of Hamburg, Martinistr. 52, 20246 Hamburg, Germany
| | - Max Heiland
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg Eppendorf, University of Hamburg, Martinistr. 52, 20246 Hamburg, Germany
| | - Tim P Jürgens
- Department of Systems Neuroscience, University Medical Center Hamburg Eppendorf, University of Hamburg, Martinistr. 52, 20246 Hamburg, Germany
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