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Saad M, Manzanera Esteve IV, Evans AG, Karagoz H, Kesayan T, Brooks-Horrar K, Sengupta S, Robison R, Johnson B, Dortch R, Thayer WP, Assi P, Gfrerer L, Kassis S. Preoperative visualization of the greater occipital nerve with magnetic resonance imaging in candidates for occipital nerve decompression for headaches. Sci Rep 2024; 14:15248. [PMID: 38956162 PMCID: PMC11219832 DOI: 10.1038/s41598-024-65334-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 06/19/2024] [Indexed: 07/04/2024] Open
Abstract
Occipital nerve decompression is effective in reducing headache symptoms in select patients with migraine and occipital neuralgia. Eligibility for surgery relies on subjective symptoms and responses to nerve blocks and Onabotulinum toxin A (Botox) injections. No validated objective method exists for detecting occipital headache pathologies. The purpose of the study is to explore the potential of high-resolution Magnetic Resolution Imaging (MRI) in identifying greater occipital nerve (GON) pathologies in chronic headache patients. The MRI protocol included three sequences targeting fat-suppressed fluid-sensitive T2-weighted signals. Visualization of the GON involved generating 2-D image slices with sequential rotation to track the nerve course. Twelve patients underwent pre-surgical MRI assessment. MRI identified four main pathologies that were validated against intra-operative examination: GON entanglement by the occipital artery, increased nerve thickness and hyperintensity suggesting inflammation compared to the non-symptomatic contralateral side, early GON branching with rejoining at a distal point, and a connection between the GON and the lesser occipital nerve. MRI possesses the ability to visualize the GON and identify suspected trigger points associated with headache symptoms. This case series highlights MRI's potential to provide objective evidence of nerve pathology. Further research is warranted to establish MRI as a gold standard for diagnosing extracranial contributors in headaches.
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Affiliation(s)
- Mariam Saad
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | | | - Adam G Evans
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Huseyin Karagoz
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Tigran Kesayan
- Department of Anesthesiology, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Krista Brooks-Horrar
- Department of Neurology, Tennessee Valley Healthcare System, Nashville, TN, 37212, USA
| | - Saikat Sengupta
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Ryan Robison
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
- Philips Healthcare, Nashville, TN, 37219, USA
| | - Brian Johnson
- Philips Healthcare, Nashville, TN, 37219, USA
- University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | | | - Wesley P Thayer
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Patrick Assi
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Lisa Gfrerer
- Division of Plastic and Reconstructive Surgery, Weill Cornell, New York, NY, 10065, USA
| | - Salam Kassis
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, 37232, USA.
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Stephens E, Dhanasekara CS, Montalvan V, Zhang B, Bassett A, Hall R, Rodaniche A, Robohm-Leavitt C, Shen CL, Kahatuduwa CN. Utility of Repetitive Transcranial Magnetic Stimulation for Chronic Daily Headache Prophylaxis: A Systematic Review and Meta-Analysis. Curr Pain Headache Rep 2024; 28:149-167. [PMID: 38277066 DOI: 10.1007/s11916-024-01210-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2024] [Indexed: 01/27/2024]
Abstract
PURPOSE OF REVIEW Management of chronic daily headaches (CDH) remains challenging due to the limited efficacy of standard prophylactic pharmacological measures. Several studies have reported that repetitive transcranial magnetic stimulation (rTMS) can effectively treat chronic headaches. The objective was to determine the utility of rTMS for immediate post-treatment and sustained CDH prophylaxis. RECENT FINDINGS All procedures were conducted per PRISMA guidelines. PubMed, Scopus, Web of Science, and ProQuest databases were searched for controlled clinical trials that have tested the efficacy of rTMS on populations with CDH. DerSimonian-Laird random-effects meta-analyses were performed using the 'meta' package in R to examine the post- vs. pre-rTMS changes in standardized headache intensity and frequency compared to sham-control conditions. Thirteen trials were included with a combined study population of N = 538 patients with CDH (rTMS, N = 284; Sham, N = 254). Patients exposed to rTMS had significantly reduced standardized CDH intensity and frequency in the immediate post-treatment period (Hedges' g = -1.16 [-1.89, -0.43], p = 0.002 and Δ = -5.07 [-10.05, -0.11], p = 0.045 respectively). However, these effects were sustained marginally in the follow-up period (Hedges' g = -0.43 [-0.76, -0.09], p = 0.012 and Δ = -3.33 [-5.52, -1.14], p = 0.003). Significant between-study heterogeneity was observed, at least partially driven by variations in rTMS protocols. Despite the observed clinically meaningful and statistically significant benefits in the immediate post-treatment period, the prophylactic effects of rTMS on CDH do not seem to sustain with discontinuation. Thus, the cost-effectiveness of the routine use of rTMS for CDH prophylaxis remains questionable. REGISTRATION Protocol preregistered in PROSPERO International Prospective Register of Systematic Reviews (CRD42021250100).
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Affiliation(s)
- Emily Stephens
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Chathurika S Dhanasekara
- Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Victor Montalvan
- Department of Neurology, School of Medicine, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, TX, 79430, USA
- Department of Neurology, Division of Vascular Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Bei Zhang
- Division of Physical Medicine and Rehabilitation, Department of Neurology, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Ashley Bassett
- Department of Laboratory Science and Primary Care, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Rebecca Hall
- Department of Laboratory Science and Primary Care, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Alyssa Rodaniche
- Department of Laboratory Science and Primary Care, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Christina Robohm-Leavitt
- Department of Laboratory Science and Primary Care, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Chwan-Li Shen
- Department of Pathology, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Center of Excellence for Integrative Health, Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Center of Excellence for Translational Neuroscience and Therapeutics, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Chanaka N Kahatuduwa
- Department of Neurology, School of Medicine, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, TX, 79430, USA.
- Center of Excellence for Integrative Health, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
- Center of Excellence for Translational Neuroscience and Therapeutics, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
- Department of Psychiatry, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
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Knoedler L, Chartier C, Casari ME, Amador RO, Odenthal J, Gfrerer L, Austen WG. Relative Pain Reduction and Duration of Nerve Block Response Predict Outcomes in Headache Surgery: A Prospective Cohort Study. Plast Reconstr Surg 2023; 152:1319-1327. [PMID: 37067978 DOI: 10.1097/prs.0000000000010552] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Abstract
BACKGROUND Experts agree that nerve block (NB) response is an important tool in headache surgery screening. However, the predictive value of NBs remains to be proven in a prospective fashion. METHODS Pre-NB and post-NB visual analogue pain scores (0 to 10) and duration of NB response were recorded prospectively. Surgical outcomes were recorded prospectively by calculating the Migraine Headache Index (MHI) preoperatively and postoperatively at 3 months, 12 months, and every year thereafter. RESULTS The study population included 115 patients. The chance of achieving MHI percentage improvement of 80% or higher was significantly higher in subjects who reported relative pain reduction of greater than 60% following NB versus less than or equal to 60% [63 of 92 (68.5%) versus 10 of 23 (43.5%); P = 0.03]. Patients were more likely to improve their MHI 50% or more with relative pain reduction of greater than 40% versus 40% or less [82 of 104 (78.8%) versus five of 11 (45.5%); P = 0.01]. In subjects with NB response of greater than 15 days, 10 of 13 patients (77.0%) experienced MHI improvement of 80% or greater. Notably, all of these patients (100%) reported MHI improvement of 50% or greater, with mean MHI improvement of 88%. Subjects with a NB response of 24 hours or more achieved significantly better outcomes than patients with a shorter response (72.7% ± 37.0% versus 46.1% ± 39.7%; P = 0.02). However, of 14 patients reporting NB response of less than 24 hours, four patients had MHI improvement of 80% or greater, and seven, of 50% or greater. CONCLUSIONS Relative pain reduction and duration of NB response are predictors of MHI improvement after headache surgery. NBs are a valuable tool to identify patients who will benefit from surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Affiliation(s)
- Leonard Knoedler
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Christian Chartier
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Maria E Casari
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Ricardo O Amador
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Jan Odenthal
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Lisa Gfrerer
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine
| | - William G Austen
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
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Dhanasekara CS, Payberah D, Chyu JY, Shen CL, Kahathuduwa CN. The effectiveness of botulinum toxin for chronic tension-type headache prophylaxis: A systematic review and meta-analysis. Cephalalgia 2023; 43:3331024221150231. [PMID: 36786349 DOI: 10.1177/03331024221150231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND A systematic and meta-analysis was conducted to examine the evidence of the effects of botulinum toxin A on chronic tension-type headache. METHODS Cochrane, Embase, Ovid, ProQuest, PubMed, Scopus, Web-of-Science databases, and ClinicallTrials.gov registry were systematically searched for studies examining the effects of botulinum toxin A on tension-type headaches. The records were screened by two independent reviewers using pre-determined eligibility criteria. DerSimonian Liard random-effects meta-analyses were performed using the 'meta' package (5.2-0) in R (4.2.0). Risk of bias and quality of evidence were assessed using the Cochrane Collaboration's Tool RoB 2 and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Clinical significance was determined using pre-defined minimal clinically important differences. RESULTS Eleven controlled trials were included (390 botulinum toxin A, 297 controls). Botulinum toxin A was associated with significant improvements in standardized headache intensity (-0.502 standard deviations [-0.945, -0.058]), headache frequency (-2.830 days/month [-4.082, -1.578]), daily headache duration (-0.965 [-1.860, -0.069]) and the frequency of acute pain medication use (-2.200 days/month [-3.485, -0.915]) vs controls. Botulinum toxin A-associated improvements exceeded minimal clinically important differences for headache intensity, frequency, and acute pain medication use. A 79% (28%, 150%) greater response rate was observed for botulinum toxin A vs controls in improving chronic tension-type headache. Treatment of eight chronic tension-type headache patients was sufficient to elicit a therapeutic response in one patient. CONCLUSIONS Corroborating the current mechanistic evidence, our meta-analysis supports the utility of botulinum toxin A for managing chronic tension-type headaches. However, due to limitations in the quality of evidence, adequately-powered high-quality controlled trials examining the effects of Botulinum toxin A on chronic tension-type headache are warranted. REGISTRATION Protocol preregistered in PROSPERO International Prospective Register of Systematic Reviews (CRD42020178616).
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Affiliation(s)
- Chathurika S Dhanasekara
- Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Daniel Payberah
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Joanna Y Chyu
- School of Medicine, University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - Chwan-Li Shen
- Department of Pathology, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA.,Center of Excellence for Integrative Health, Texas Tech University Health Sciences Center, Lubbock, TX, USA.,Center of Excellence for Translational Neuroscience and Therapeutics, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Chanaka N Kahathuduwa
- Center of Excellence for Integrative Health, Texas Tech University Health Sciences Center, Lubbock, TX, USA.,Center of Excellence for Translational Neuroscience and Therapeutics, Texas Tech University Health Sciences Center, Lubbock, TX, USA.,Department of Psychiatry, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA.,Department of Neurology, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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