Efficacy of Sphenopalatine Ganglion Radiofrequency in Refractory Chronic Cluster Headache

doi:10.1016/j.wneu.2018.10.007

World Neurosurgery

Volume 122, February 2019, Pages e262-e269

https://doi.org/10.1016/j.wneu.2018.10.007 Get rights and content

Highlights

•
Radiofrequency of the SPG is a safe, fast, and partially effective method for the treatment of CCHr.
•
We found no evidence of significant superiority of one SPG radiofrequency modality over the other in CCHr.
•
Given the higher rate of complications related to RFA, we recommend the used of PRF.
•
We consider radiofrequency as one of the first options for invasive treatment in CCHr.

Background

In the literature, there are only short series of radiofrequency of the sphenopalatine ganglion (SPG) to treat chronic refractory cluster headache (CCHr) with variable results. Furthermore, there is no consensus on which methodology to use: radiofrequency ablation (RFA) or pulsed radiofrequency (PRF).

Methods

We conducted a prospective analysis of 37 patients with CCHr who underwent RFA or PRF of the SPG in our center between 2004 and 2015.

Results

The mean age of the patients was 40 years (range, 26–59 years). PRF was performed in 24 patients, and RFA was performed in 13 patients. A total of 5 patients (13.5%) experienced complete clinical relief of both pain and parasympathetic symptoms, 21 patients (56.8%) had partial and transient relief, and 11 patients (29.7%) did not improve. There was no evidence of significant superiority of one radiofrequency modality over the other (P = 0.48). There were no complications associated with the technique. The passage of time tended to decrease the efficacy of both techniques (P < 0.001). The mean follow-up was 68.1 months (range, 15–148 months). To our knowledge, this is the series with the largest number of patients and the longest follow-up period published in the literature.

Conclusions

Radiofrequency of the SPG is a safe, fast, and partially effective method for the treatment of CCHr. Given its low rate of complications and its low economic cost, we think it should be one of the first invasive treatment options, prior to techniques with greater morbidity and mortality, such as neuromodulation.

Introduction

Cluster headache (CH) is a severe and disabling primary headache that belongs to the group of autonomic trigeminal headaches. According to the criteria of the International Classification of Headache Disorders 3rd Edition (Table 1), it is characterized by episodic unilateral headache attacks ranging in duration from 15 to 180 minutes, accompanied by parasympathetic ipsilateral symptoms.¹ Approximately 10% of CHs are chronic, generating recurrent attacks with no pain free periods longer than 1 month for a minimum of 1 year, and 10% of them become refractory to pharmacologic treatments. Chronic refractory cluster headache (CCHr) is a devastating condition with profound negative effects on the life of patients, a fact that has led to it being known as the suicide headache.²

Being considered by some as the worst pain a human can experience,³ several nonpharmacologic invasive methods have been used in these patients during the last decades.⁴ These include injurious surgical procedures focusing primarily on the trigeminal ganglion and, more recently, techniques based on neuromodulation, both at central and peripheral levels.5, 6 These techniques include variable effectiveness rates and life-threatening complications.

Radiofrequency of the sphenopalatine ganglion (SPG) was described by Salar et al. in 1987.⁷ Although the pathogenesis of CH has not been completely elucidated, the SPG has traditionally been considered to be involved in the pathophysiology of CH.8, 9 SPG radiofrequency is a quick and simple technique that has proven its efficacy in episodic CH, having been used in a short series of chronic CHs with variable results. Because the heat on the tip of the needle can be accurately controlled and regulated, it is theoretically considered the most selective method of blocking the SPG; however, there is no consensus on which methodology to use: radiofrequency ablation (RFA) or pulsed radiofrequency (PRF).10, 11

This study prospectively evaluates the efficacy of SPG radiofrequency, based on data from 37 patients with CCHr, after a mean follow-up period of 68 months. We also analyze the complications of the technique and make a comparison between RFA and PRF. To our knowledge, this is the largest series of patients with the longest follow-up period published so far in the literature.

Section snippets

Patients

After the approval of the study by the ethics committee of our hospital, the data were collected prospectively by means of pain diaries and questionnaires and reviewing medical notes.

Between 2004 and 2014, a total of 37 patients diagnosed with CCH according to the criteria of the International Classification of Headache Disorders 3rd Edition were treated.¹ All patients met the previously published criteria of treatment refractoriness. Because of the invasive nature of the technique, additional

Results

The main characteristics of each patient are summarized in Table 2.

In total, 37 patients were treated with radiofrequency: 29 patients were men (78%) and 8 were women (22%). The mean age at onset of headache was 31 years (range, 15–56 years), with the mean age of chronicity being 35 years (range, 21–56 years). The mean age at the time of the first treatment was 40 years (range, 26–59 years).

In 20 patients the affected side was the right, and in 17 patients the affected side was the left. Eleven

Discussion

Our results showed that radiofrequency of the SPG is a safe and partially effective method to treat CCHr. After a mean follow-up period of 68 months, we did not record any adverse effects related to the procedure.

Despite that in our series the percentage of patients who presented clinical transient improvement and also the percentage of asymptomatic patients after PRF was slightly higher than after RFA, the difference was not statistically significant.

Only 5 cases in which the symptoms

Conclusions

SPG radiofrequency is a quick, partially effective, economic, and safe method with a low level of complications. Because of these characteristics, this technique must be taken into consideration in relation to other invasive treatments with a greater number of complications and economic cost to treat CCHr.

There are no statistical differences between RFA and PRF. Because of the similarity in efficacy and the greater theoretical risk of thermal complications, we recommend the use of the pulsed

Acknowledgments

The authors thank Dr. Ignasi Gich for his contribution to the statistical analysis of the manuscript.

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Of 103 eligible participants, 88 (85%) gave informed consent and 73 (83%) were followed for ≥2 year, 61 (69%) ≥ 3 year, 33 (38%) ≥ 5 years and 3 (3%) ≥ 8.5 years. Mean (±SD) follow-up was 4.2 ± 2.2 years for a total of 370 person years (84% of potentially 442 years). The pooled geometric mean (95% CI) weekly attack frequency remained considerably lower after one (4.2; 2.8–6.3), two (5.1; 3.5–7.6) and five years (4.1; 3.0–5.5) compared to baseline (16.2; 14.4–18.3). Of the 49/88 (56%) ICON ≥50% responders, 35/49 (71%) retained this response and 15/39 (38%) ICON non-responders still became a ≥50% responder for at least half the follow-up period. Most participants (69/88; 78% [0.68–0.86]) reported a subjective improvement from baseline at last follow-up and 70/88 (81% [0.70–0.87]) would recommend ONS to others. Hardware-related surgery was required in 44/88 (50%) participants in 112/122 (92%) events (0.35 person-year⁻¹ [0.28–0.41]). We didn't find predictive factors for effectiveness.
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Citation Excerpt :
Individuals with cluster headaches have been refractory to pharmacologic and interventional nonpharmacologic treatments, resulting in variable effectiveness.4 A prospective study by Salgado-Lopez and colleagues4 investigated the usefulness of either RFA or PRF to help treat chronic refractory cluster headache. For the study population, the mean age was 40 years with a range of 26 to 59 years.
Efficacy and safety of surgical treatment of cluster headache
2020, Medicina Clinica
La cefalea en racimos (CR) es la cefalea humana más grave y se cronifica en un 10-20% de los pacientes, pudiendo llegar a ser refractaria a todos los fármacos eficaces en un 10% de ellos. En este escenario se indican procedimientos quirúrgicos: radiofrecuencias del ganglio esfenopalatino ipsilateral al dolor (RF-GEFP), estimulación bilateral de los nervios occipitales (E-NOM) y estimulación cerebral profunda (ECP) del hipotálamo posteroinferior ipsilateral. Se ha analizado específicamente la eficacia y seguridad de cada una de ellas, pero no se ha descrito la evolución de una serie de pacientes siguiendo este itinerario quirúrgico por orden de agresividad.
Pacientes con CR crónica y refractaria según los criterios de la European Headache Federation. Fueron sometidos secuencialmente a RF-GEFP, E-NOM si ineficacia del anterior y ECP si ineficacia del anterior.
Incluimos prospectivamente a 44 pacientes entre noviembre de 2003 y junio de 2018 con una edad media de 38,3 años siendo el 70% hombres. El seguimiento medio fue de 87,4 meses. Respondieron a 74 procedimientos de RF-GEFP 19 pacientes (33,3%). De los 25 restantes, se implantó un dispositivo de E-NOM en 22 de ellos, mostrando una eficacia del 50%. Finalmente, se sometieron a ECP del hipotálamo posteroinferior ipsilateral 9 pacientes con una eficacia del 88,8%. No se constataron complicaciones graves en ninguno de los 3 procedimientos.
La aplicación secuencial de los 3 procedimientos quirúrgicos logró revertir la grave situación de CR crónica y refractaria a una CR episódica en el 93% de los pacientes con una morbilidad quirúrgica aceptable.
Cluster headache (CR) is the most severe human headache and is chronic in 10%-20% of patients, and 10% can become refractory to all effective drugs. In this scenario, surgical procedures are indicated: radiofrequencies of the sphenopalatine ganglion ipsilateral to pain (RF-SPG), bilateral stimulation of the occipital nerves (NOM-S) and deep brain stimulation (DBS) of the ipsilateral posterior hypothalamus. The efficacy and safety of each of these procedures has been specifically analyzed, but the progress of a series of patients following this surgical route in order of aggressiveness has not been described.
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We prospectively included 44 patients between November 2003 and June 2018 with an average age of 38.3 years; 70% were men. The mean follow-up was 87.4 months. Nineteen patients responded to 74 procedures of RF-SPG (33.3%). Of the remaining 25 patients, a NOM-S device was implanted in 22, showing an efficacy of 50%. Finally, 9 patients underwent ECP of the ipsilateral lower-posterior hypothalamus with an efficacy of 88.8%. No serious complications were found following any of these 3 procedures.
The sequential application of these three surgical procedures succeeded in reversing the serious situation of chronic CR refractory to an episodic CR in 93% of patients with acceptable surgical morbidity.
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: Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Original ArticleEfficacy of Sphenopalatine Ganglion Radiofrequency in Refractory Chronic Cluster Headache

Highlights

Background

Methods

Results

Conclusions

Introduction

Section snippets

Patients

Results

Discussion

Conclusions

Acknowledgments

Pain

World Neurosurg

The International Classification of Headache Disorders, 3rd edition

Cephalalgia

Refractory chronic cluster headache: a consensus statement on clinical definition from the European Headache Federation

J Headache Pain

The neuropsychology of cluster headache: cognition, mood, disability, and quality of life of patients with chronic and episodic cluster headache

Headache

Sphenopalatine ganglion block-80 years later

Reg Anesth

Neurostimulation in cluster headache: a review of current progress

Cephalalgia

Percutaneous thermocoagulation for sphenopalatine ganglion neuralgia

Acta Neurochir

The sphenopalatine ganglion: anatomy, pathophysiology, and therapeutic targeting in headache

Headache

Evidence-based interventional pain medicine according to clinical diagnoses. 2. Cluster headache

Pain Pract

Computerized tomography-guided sphenopalatine ganglion pulsed radiofrequency treatment in 16 patients with refractory cluster headaches: twelve- to 30-month follow-up evaluations

Cephalalgia

Sphenopalatine ganglion radiofrequency ablation for the management of chronic cluster headache

Headache

Retrospective analysis of radiofrequency lesions of the sphenopalatine ganglion in the treatment of 19 cluster headache patients

Pain Clin

Efficacy of sphenopalatine ganglion blockade in 66 patients suffering from cluster headache: a 12- to 70-month follow-up evaluation

J Neurosurg

Cluster headache: potential options for medically refractory patients (when all else fails)

Headache

Original Article
Efficacy of Sphenopalatine Ganglion Radiofrequency in Refractory Chronic Cluster Headache