October 25, 2019
Reviewing Interventional Treatments for Chronic Headache
When chronic headaches and facial pain are complicated by comorbidities, polypharmacy, intolerance, or refractory pain, some clinicians are turning to interventional modalities to ease headache pain.1 Patients who cannot get relief with acute treatment were found to be 2 to 3 times more likely to transition to chronic migraine.2
Interventions to treat the most common types of primary headache — migraine, tension-type headache, and trigeminal neuralgia — include nerve blocks, decompression surgery, and steroid injections.1 Unlike oral pharmacotherapy, the interventions directly inhibit the painful nerves.1 The evidence base supporting the use of such interventions is still scant, leaving clinicians to rely on studies with small sample sizes and limited case reports.
Transnasal sphenopalatine ganglion block
A modality that is gaining interest is the use of transnasal sphenopalatine ganglion (SPG) block for migraine, cluster headache, and trigeminal neuralgia because it is not invasive.2 Neurologist Mohamed Binfalah, MD, ABPN, from the University Medical Center, King Abdullah Medical City, in Adliya, Bahrain, and colleagues tested the technique in 55 patients (mean age, 37.9 years; 72.7% women) with the use of a sphenopalatine catheter filled with 2 mL of 2% lidocaine administered via each nostril.2
A total of 70.9%, 78.2%, and 70.4% of patients reported being free of headache 15 minutes, 2 hours, and 24 hours, respectively, after the procedure.2 The great majority of patients (98.1%) reported feeling “very good” or “good” 2 and 24 hours after the intervention, as assessed with the Patient Global Impression of Change scale. Adverse events were mild and lasted less than 24 hours, but patients reported throat numbness, nausea (10.9%), dizziness (10.9%), vomiting (1.8%), and nasal discomfort (18.2%).2
“I don’t believe we have clear guidelines on the proper timing for using interventions in headache management,” remarked Dr Binfalah. “Some experts recommend using these interventions for refractory cases, but I think that it is reasonable to use interventions such as SPG blocks early in specific circumstances such as acute migraines not responding to analgesics, status migrainosus, migraine in pregnancy, acute cluster headaches, and in patients with low compliance or specific contraindications for oral or injectable analgesics and prevention medications.”
Peripheral nerve blocks
In a population that is often coping with polypharmacy, comorbidities, and cognitive decline, clinicians are often limited in their prescribing repertoire. Therefore, researchers sought to determine the efficacy of peripheral nerve blocks (PNBs) on headaches in people age ≥65 years.3 In this retrospective chart study, 64 patients (mean age, 71 years; 78% women; average, 23 headache days per month) who had chronic migraine, episodic migraine, trigeminal autonomic cephalalgia, or occipital neuralgia were enrolled. Most of the patients were taking at least 1 medication and nearly half had hypertension. Comorbidities in this cohort included hyperlipidemia, arthritis, depression, and anxiety.
During the 6-year study period, patients received an average of 4 PNB treatments. Many of the PNB consisted of local anesthetics injected into the bilateral greater and lesser occipital nerves and the auriculotemporal, supraorbital, or supratrochlear nerves. The most frequently used analgesic was 0.5% bupivacaine alone, followed by 0.5% bupivacaine and 40 mg methylprednisolone. Overall, 73% of patients reported headache relief; patients with chronic migraine achieved the best results, with 81% reporting treatment efficacy. Neither patients nor the clinicians reported any adverse events.
“In lieu of the efficacy of peripheral nerve blocks and given the relatively high side effect profiles of many headache prophylactic medications, I hope that clinicians think twice before treating older adults and geriatric patients with oral pharmacotherapy for headache prophylaxis,” noted one of the study authors, Jacob R. Hascalovici, MD, PhD, from Montefiore Medical Center at Albert Einstein College of Medicine in the Bronx, New York. “Specifically, the medications that are considered contraindicated in the older adult and geriatric population according to the Beers Criteria medication list.”4
Decompression may be key to pain relief
In patients with unremitting head and neck pain, occipital nerve decompression surgery may provide lasting relief by freeing the lesser and greater occipital nerves at the level at which they innervate the posterior cervical muscles. Pain in these patients may present like a chronic migraine, for which the centrally acting membrane-stabilizing agents are not effective.5
“It is helpful to think of occipital nerve compression in the same way that we would think of other nerve compression syndromes, perhaps carpal tunnel syndrome,” said neurologist Pamela Blake, MD, from the University of Texas Health Science Center in Houston. “We would likely start with interventions directed at reducing the nerve compression, such as immobilizing with wrist splints at night, and counseling the patient to avoid activities that provoke nerve irritation. I would encourage a somewhat similar approach to a patient with occipital nerve compression, with treatments directed at the nerves — perhaps occipital steroid injections and counseling the patient to avoid the neck positions that may aggravate pain — and perhaps try 2 or 3 oral preventives.”
Repetitive pericranial nerve blocks for paroxysmal hemicrania
For the rare cases of paroxysmal hemicrania that are refractory to treatment with indomethacin, interventions such as repetitive pericranial nerve blocks may provide relief.6 Because the incidence of paroxysmal hemicrania is so rare — as are patients who are resistant to indomethacin — the evidence base is too small to recommend one modality over another.
“Interventional headache management therapies using local anesthetics with or without corticosteroids are inexpensive and affordable treatment options,” explained neurologist Devrimsel Harika Ertem, MD, from the Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences in Istanbul, Turkey.
“However, the effects of cranial nerve blocks in patients with chronic paroxysmal hemicrania still remain unclear,” noted Dr Ertem. “Neuromodulation procedures, such as occipital nerve stimulation, vagus nerve stimulation and deep brain stimulation in the posterior hypothalamus are promising treatment options for patients with headache who are unable to tolerate indomethacin. Unexpected bleeding, pain at injection sites, local anesthetics toxicity, iatrogenic pneumothorax, and nerve injury are rare but side effects of interventional therapies that should not be ignored.”
Summary & Clinical Applicability
Interventional pain modalities provide alternative analgesia for patients who are intolerant of pharmacologic agents, have comorbidities that require multiple medications, or have pain refractory to oral medications. Large randomized prospective trials are needed to test the efficacy of these modalities.
- Gupta R, Fisher K, Pyati S. Chronic headache: a review of interventional treatment strategies in headache management. Curr Pain Headache Rep. 2019;23(9):68. doi:10.1007/s11916-019-0806-9
- Binfalah M, Alghawi E, Shosha E, Alhilly A, Bakhiet M. Sphenopalatine ganglion block for the treatment of acute migraine headache. Pain Res Treat. 2018;2018:2516953. doi:10.1155/2018/2516953
- Hascalovici JR, Robbins MS. Peripheral nerve blocks for the treatment of headache in older adults: a retrospective study. Headache. 2017;57(1):80-86. doi:10.1111/head.12992
- 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019;67(4):674-694. doi:10.1111/jgs.15767
- Blake P, Burstein R. Emerging evidence of occipital nerve compression in unremitting head and neck pain. J Headache Pain. 2019;20(1):76. doi:10.1186/s10194-019-1023-y
- Ertem DH. Are repetitive pericranial nerve blocks effective in the management of chronic paroxysmal hemicrania?: a case report. Medicine (Baltimore). 2019;98(31):e16484. doi:10.1097/MD.0000000000016484
This article originally appeared on Clinical Pain Advisor