Stimulation of the sphenopalatine ganglion in intractable cluster headache: Expert consensus on patient selection and standards of care

Abstract

Context and overview: Chronic cluster headache (CCH) is a debilitating headache disorder with a significant impairment of the patients' lives. Within the past decade, various invasive neuromodulatory approaches have been proposed for the treatment of CCH refractory to standard preventive drug, but only very few randomized controlled studies exist in the field of neuromodulation for the treatment of drug-refractory headaches. Based on the prominent role of the cranial parasympathetic system in acute cluster headache attacks, high-frequency sphenopalatine ganglion (SPG) stimulation has been shown to abort ongoing attacks in some patients in a first small study. As preventive effects of SPG-stimulation have been suggested and the rate of long-term side effects was moderate, SPG stimulation appears to be a promising new treatment strategy. Aims and conclusion: As SPG stimulation is effective in some patients and the first commercially available CE-marked SPG neurostimulator system has been introduced for cluster headache, patient selection and care should be standardized to ensure maximal efficacy and safety. As only limited data have been published on SPG stimulation, standards of care based on expert consensus are proposed to ensure homogeneous patient selection and treatment across international headache centres. Given that SPG stimulation is still a novel approach, all expert-based consensus on patient selection and standards of care should be re-reviewed when more long-term data are available.

Topical Sphenopalatine Ganglion Block Compared With Epidural Blood Patch for Postdural Puncture Headache Management in Postpartum Patients

“…Release of these chemicals may also increase plasma protein extravasation and cause neurogenic inflammation, leading to activation of trigeminal nociceptors and contributing to the headaches. 32 Intranasal lidocaine administration anesthetizes the sphenopalatine ganglion and decreases the nociceptor signaling, which relieves the PDPH. 33 What remains unexplained is the ability of a short-acting agent, such as lidocaine to permanently turn off the PDPH symptoms even after the pharmacological effect of the medication wears off, but interestingly, this block appears to have a similar permanent effect in the treatment of migraines.…”

The Sphenopalatine Ganglion: Anatomy, Pathophysiology, and Therapeutic Targeting in Headache

“…SPG activation may result in the release of acetylcholine, vasoactive intestinal peptide and nitric oxide in dural blood vessels. This may increase plasma protein extravasation with resultant neurogenic inflammation and activation of trigeminal nociceptors contributing to pain and triggering headache …”

“…Lambru and Matharu suggest that clinical use of peripheral nerve stimulation is limited by lack of proper controlled data and should only be considered in patients with primary chronic headache disorders who have failed therapies recommended by international guidelines . An expert consensus on patient selection including inclusion and exclusion criteria as well as standards of care for stimulation of the SPG in patients with intractable CH has been recently published . However, more studies investigating SPG stimulation are underway at the time of this writing.…”

Hemicrania continua may respond to repetitive sphenopalatine ganglion block: A case report

“…6,7,23 SPG modulation using other techniques, such as electrical stimulation, chemical neurolysis, microvascular decompression, and surgical or radiofrequency ablation, has also been performed for a variety of head pain conditions. [24][25][26][27] However, these interventions may be associated with significant adverse effects.…”