Migraine Headache Following Stellate Ganglion Block for Reflex Sympathetic Dystrophy

Abstract

The alteration of extracranial blood flow in conjunction with clinical signs of autonomic nervous system dysfunction have led to various explanations concerning the pathophysiology of migraine headache.Reflex sympathetic dystrophy, a painful disorder of the sympathetic nervous system, can be treated by blocking the sympathetic nerves located in the stellate ganglion, resulting in vasodilation, ptosis, miosis, and anhydrosis. In theory, these changes could trigger a migraine headache attack secondary to autonomic dysfunction reflecting an imbalance between sympathetic and parasympathetic nervous systems. This may be especially true in a patient with a previous history of meningitis that may have resulted in a disorder of cerebrovescular regulation. We report a 56-year-old man with no previous history of migraine who developed migraine with aura after a stellate ganglion block. Those episodic headaches occurred with decreasing frequency end severity for over 6 months, with eventual complete resolution. This interesting phenomenon has not been reported in the English literature and may help to better understand the pathophysiology of migraine.Key words: migraine, meningitis, stellate ganglion block, reflex sympathetic dystrophy, oculosympathetic paresis (Horner's syndrome), sumatriptan (Headache 1996;36:335-337) The International Headache Society (IHS) defines a typical attack of migraine without aura as a moderate to severe throbbing, usually unilateral headache associated with nausea, anorexia, phonophobia, and photophobia which occurs one to four times per month lasting 4 to 72 hours (untreated or unsuccessfully treated), aggravated by physical activity, and usually improved with sleep. This definition of migraine is comprehensive and requires five previous attacks and is often familial. The definition of migraine with aura requires two attacks and concentrates on the details and timing of the aura. 1,2 Three of the following four characteristics must be noted (1) one or more fully reversible symptoms, (2) at least one aura symptom develops gradually over 4 minutes or two or more symptoms occur in succession, (3) no aura symptom lasts more than 60 minutes, and (4) headache follows aura with a free interval of less than 60 minutes.There is some evidence that an increase in extracranial blood flow contributes to pain in some migraine sufferers, particularly in patients with clear signs of ocular sympathetic deficit on the usual side of the headache. 3 We report a case of apparent migraine headache with aura following a stellate ganglion block. To our knowledge, this is the first case report describing this phenomena. CASE HISTORYA 56-year-old right-handed man was evaluated at our pain management center for symptoms consistent with the diagnosis of reflex sympathetic dystrophy (RSD) involving his left upper extremity. Two years previously, the patient was injured when a piece of glass penetrated the skin between the second and third metacarpals of his left hand. This area was explored and a 3 to 4 mm piece of gl...

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