Effectiveness of transcranial direct current stimulation (tDCS) as adjunctive treatment for chronic headache in adults with clinically stable systemic lupus erythematosus (SHADE): a randomised double-blind multiarm sham controlled clinical trial.

BACKGROUND: Chronic headache is a 'silent' neuropsychiatric systemic lupus erythematosus symptom with heterogeneous prevalence, potentially reaching 54.4%. It may reduce quality of life by increasing the likelihood of depression and sleep disturbance. While pharmacotherapy remains the first-line treatment, the current management is still challenging and needs other non-invasive modalities. An effective, tolerable and disease-specific treatment modality including transcranial direct current stimulation (tDCS) is considered to reduce the frequency of chronic headaches, including in SLE. Until recently, there was no standard protocol for tDCS in treating headaches. METHODS AND ANALYSIS: SHADE is a single-centre randomised double-blind multiarm sham-controlled trial for adults with clinically stable SLE, chronic headaches and without history of traumatic brain injury, brain infection, stroke or brain tumour. Random allocation is conducted to 88 subjects into 3 treatment groups (administration at primary motor, primary sensory and dorsolateral prefrontal cortex) and control group in 1:1:1:1 ratio. The primary endpoint is reduced number of headache days after adjunctive tDCS. The secondary endpoints are reduced headache intensity, increased quality of life, increased sleep quality, decreased depression and reduced analgesics use. The outcome is measured monthly until 3-month postintervention using headache diary, 36-Item Short Form Survey, Chronic Headache Quality of Life Questionnaire, Pittsburgh Sleep Quality Index and Mini International Neuropsychiatry Interview version 10 (MINI ICD 10). Intention-to-treat analysis will be performed to determine the best tDCS electrode placement. ETHICS AND DISSEMINATION: Ethical approval had been obtained from the local Institutional Review Board of Faculty of Medicine Universitas Indonesia. Results will be published through scientific relevant peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT05613582.

Chronic headaches and middle meningeal artery embolization.

BACKGROUND: The middle meningeal artery (MMA) has been implicated in chronic headaches, but no studies have examined the relationship between MMA embolization and headaches. METHODS: Patients treated with MMA embolization for a chronic subdural hematoma (cSDH) between January 1, 2018, and December 31, 2020, were retrospectively assessed. Patients with a Glasgow Coma Scale (GCS) score of 15 at discharge received a follow-up telephone call to assess their history of chronic headache, defined as a headache ≥2 years before the cSDH and symptoms ≥2 days/month. A Headache Impact Test (HIT-6) was performed during the follow-up telephone call. The primary outcome was resolution or improvement of headaches after embolization. RESULTS: Of 76 patients undergoing MMA embolization for a cSDH during the study period, 56 (74%) had a discharge GCS score of 15. Of these 56 patients, 46 (82%) responded to a follow-up telephone call and were analyzed (mean [SD] age 68 [11] years; 36 [78%] men and 10 [22%] women). Nine (20%) reported chronic headaches before embolization. With a mean (SD) follow-up of 489 (173) days, eight of the nine patients reported improvement of chronic headaches, with seven having complete resolution. For these nine patients, the mean (SD) HIT-6 score was significantly higher before embolization than after embolization (64 [7.1] vs 40 [9.1], p<0.001). CONCLUSION: In patients with chronic headaches who underwent MMA embolization for a cSDH, the majority reported improvement of headaches after the procedure. Future prospective studies are warranted to assess the usefulness of MMA embolization to treat chronic headaches.

Diagnosis and Management of Headache: A Review.

IMPORTANCE: Approximately 90% of people in the US experience headache during their lifetime. Migraine is the second leading cause of years lived with disability worldwide. OBSERVATIONS: Primary headache disorders are defined as headaches that are unrelated to an underlying medical condition and are categorized into 4 groups: migraine, tension-type headache, trigeminal autonomic cephalalgias, and other primary headache disorders. Studies evaluating prevalence in more than 100 000 people reported that tension-type headache affected 38% of the population, while migraine affected 12% and was the most disabling. Secondary headache disorders are defined as headaches due to an underlying medical condition and are classified according to whether they are due to vascular, neoplastic, infectious, or intracranial pressure/volume causes. Patients presenting with headache should be evaluated to determine whether their headache is most likely a primary or a secondary headache disorder. They should be evaluated for symptoms or signs that suggest an urgent medical problem such as an abrupt onset, neurologic signs, age 50 years and older, presence of cancer or immunosuppression, and provocation by physical activities or postural changes. Acute migraine treatment includes acetaminophen, nonsteroidal anti-inflammatory drugs, and combination products that include caffeine. Patients not responsive to these treatments may require migraine-specific treatments including triptans (5-HT1B/D agonists), which eliminate pain in 20% to 30% of patients by 2 hours, but are accompanied by adverse effects such as transient flushing, tightness, or tingling in the upper body in 25% of patients. Patients with or at high risk for cardiovascular disease should avoid triptans because of vasoconstrictive properties. Acute treatments with gepants, antagonists to receptors for the inflammatory neuropeptide calcitonin gene-related peptide, such as rimegepant or ubrogepant, can eliminate headache symptoms for 2 hours in 20% of patients but have adverse effects of nausea and dry mouth in 1% to 4% of patients. A 5-HT1F agonist, lasmiditan, is also available for acute migraine treatment and appears safe in patients with cardiovascular risk factors. Preventive treatments include antihypertensives, antiepileptics, antidepressants, calcitonin gene-related peptide monoclonal antibodies, and onabotulinumtoxinA, which reduce migraine by 1 to 3 days per month relative to placebo. CONCLUSIONS AND RELEVANCE: Headache disorders affect approximately 90% of people during their lifetime. Among primary headache disorders, migraine is most debilitating and can be treated acutely with analgesics, nonsteroidal anti-inflammatory drugs, triptans, gepants, and lasmiditan.

Peripheral Nerve Stimulation for Occipital Neuralgia.

BACKGROUND: Chronic headaches are the second most prevalent disease and second most common cause for years lived with disability worldwide. Occipital neuralgia can cause headaches or be present in addition to other more prevalent causes of headache. If these headaches fail to respond to conservative and pharmacological therapy, physicians proceed to more invasive treatments, starting with infiltration of the greater occipital nerve with local anesthetic with or without corticosteroids, followed by nerve ablation or stimulation. Occipital nerve stimulation gained more popularity as the technology improved and more pain physicians received training on interventional procedures. METHODS: In this manuscript, we are presenting our experience with ultrasound-guided implant of occipital nerve stimulators using peripheral nerve stimulator systems. After confirming appropriateness of treatment by a successful occipital nerve block (i.e., resulting in >50% relief in patients' pain intensity), we implanted five stimulator systems in three patients (two bilateral). RESULTS: We followed these patients for an average of eight months, and the average pain reduction was ∼50%. We did not observe any adverse events during or immediately after surgery. One patient developed an adverse reaction to the adhesive of the battery transmitter, but it was not severe enough to stop her from using the stimulator. CONCLUSIONS: Considering the ease of implant and minimal side effects, implant of peripheral nerve stimulators to stimulate the occipital nerve is a promising treatment modality for patients with chronic headache who present with features of occipital neuralgia. However, wider use of this treatment modality is subject to further studies.

Efficacy of Occipital Nerve Stimulation to Treat Refractory Occipital Headaches: A Single-Institution Study of 60 Patients.

BACKGROUND: Occipital nerve stimulation (ONS) is shown to be effective in treating various forms of headache. Most studies describe the treatment of occipital neuralgia (ON), but in many patients, the clinical description could also correspond to cervicogenic headache (CGH) or occipital migraine (OM). These different entities (ON, CGH, and OM) may be grouped together under the term occipital headaches. OBJECTIVE: To assess the efficacy of ONS to treat occipital headaches in a large series of patients with a long-term follow-up. MATERIALS AND METHODS: We performed a retrospective review of data on 60 patients with intractable occipital headaches treated with occipital nerve stimulation (ONS), who were referred to our center between October 2008 and October 2014. Details of pain evaluation, location, duration, cause and previous treatment were analyzed. Evaluations included the visual analog scale (VAS), the number of headache days per month (NHD), and the Medication Quantification Scale (MQS). Trials with transcutaneous electrical nerve stimulation (TENS-ONS) were performed and served as a guide for surgery indication (see Patients and Method section). RESULTS: After one year of ONS, mean VAS had decreased from 8.4/10 to 2.8/10 (72.2% reduction [p < 0.001]), and 76% of patients had at least a 50% decrease in mean VAS score. The mean MQS score decreased from 18 to 8.8, corresponding to a reduction of pain medication by an average of 50%. Adverse events concerned 12 patients (20%). Six patients presented with electrode displacement or fracture (10%) and six patients presented with cases of infection (10%) associated with the pulse generator. CONCLUSIONS: The results of this large series confirm that ONS is an effective treatment option for patients with intractable occipital headaches, but the frequency of complications remains quite high and must be taken into account in the surgical decision.

Frequent Headaches: Evaluation and Management.

Most frequent headaches are typically migraine or tension-type headaches and are often exacerbated by medication overuse. Repeated headaches can induce central sensitization and transformation to chronic headaches that are intractable, are difficult to treat, and cause significant morbidity and costs. A complete history is essential to identify the most likely headache type, indications of serious secondary headaches, and significant comorbidities. A headache diary can document headache frequency, symptoms, initiating and exacerbating conditions, and treatment response over time. Neurologic assessment and physical examination focused on the head and neck are indicated in all patients. Although rare, serious underlying conditions must be excluded by the patient history, screening tools such as SNNOOP10, neurologic and physical examinations, and targeted imaging and other assessments. Medication overuse headache should be suspected in patients with frequent headaches. Medication history should include nonprescription analgesics and substances, including opiates, that may be obtained from others. Patients who overuse opiates, barbiturates, or benzodiazepines require slow tapering and possibly inpatient treatment to prevent acute withdrawal. Patients who overuse other agents can usually withdraw more quickly. Evidence is mixed on the role of medications such as topiramate for patients with medication overuse headache. For the underlying headache, an individualized evidence-based management plan incorporating pharmacologic and nonpharmacologic strategies is necessary. Patients with frequent migraine, tension-type, and cluster headaches should be offered prophylactic therapy. A complete management plan includes addressing risk factors, headache triggers, and common comorbid conditions such as depression, anxiety, substance abuse, and chronic musculoskeletal pain syndromes that can impair treatment effectiveness. Regular scheduled follow-up is important to monitor progress.

Emerging evidence of occipital nerve compression in unremitting head and neck pain.

Unremitting head and neck pain (UHNP) is a commonly encountered phenomenon in Headache Medicine and may be seen in the setting of many well-defined headache types. The prevalence of UHNP is not clear, and establishing the presence of UHNP may require careful questioning at repeated patient visits. The cause of UHNP in some patients may be compression of the lesser and greater occipital nerves by the posterior cervical muscles and their fascial attachments at the occipital ridge with subsequent local perineural inflammation. The resulting pain is typically in the sub-occipital and occipital location, and, via anatomic connections between extracranial and intracranial nerves, may radiate frontally to trigeminal-innervated areas of the head. Migraine-like features of photophobia and nausea may occur with frontal radiation. Occipital allodynia is common, as is spasm of the cervical muscles. Patients with UHNP may comprise a subgroup of Chronic Migraine, as well as of Chronic Tension-Type Headache, New Daily Persistent Headache and Cervicogenic Headache. Centrally acting membrane-stabilizing agents, which are often ineffective for CM, are similarly generally ineffective for UHNP. Extracranially-directed treatments such as occipital nerve blocks, cervical trigger point injections, botulinum toxin and monoclonal antibodies directed at calcitonin gene related peptide, which act primarily in the periphery, may provide more substantial relief for UHNP; additionally, decompression of the occipital nerves from muscular and fascial compression is effective for some patients, and may result in enduring pain relief. Further study is needed to determine the prevalence of UHNP, and to understand the role of occipital nerve compression in UHNP and of occipital nerve decompression surgery in chronic head and neck pain.

Headache attributed to IIH: clinical evolution in IHS criteria through the years.

Idiopathic intracranial hypertension (IIH) is a condition characterized by increased intracranial pressure without a detectable cause. The most common symptom of IIH is a headache, which occurs in almost all cases at the time of diagnosis with various headache phenotypes. In clinical practice, diagnosis of headache attributed to IIH is given referring to the International Headache Society (IHS) criteria of the International Classification of Headache Disorders. In the present publication, we consider how the IHS diagnostic criteria for headache attributed to intracranial idiopathic hypertension have evolved through the years.

Cervical Foraminal Epidural Blood Patch for the Targeted Treatment of Refractory Cerebrospinal Fluid Leakage From a Dural Sleeve.

Epidural blood patches (EBPs) are routinely used to treat symptoms (eg, headaches) associated with spontaneous intracranial hypotension. Although cerebrospinal fluid leakage commonly involves the periforaminal areas of the cervical or thoracic spine, EBPs have been historically performed at the lumbar level. Recent evidence suggests that targeting the causative spinal segment may provide greater clinical benefits. While previous reports have targeted foraminal leaks with segmental thoracic or cervical injections, we present a case report detailing the novel use of a navigable epidural catheter to perform a selective EBP at the C7/T1 foramen.

Survival Analysis of Occipital Nerve Stimulator Leads Placed under Fluoroscopic Guidance with and without Ultrasonography.

BACKGROUND: Electrical stimulation of the greater occipital nerves is performed to treat pain secondary to chronic daily headaches and occipital neuralgia. The use of fluoroscopy alone to guide the surgical placement of electrodes near the greater occipital nerves disregards the impact of tissue planes on lead stability and stimulation efficacy. OBJECTIVE: We hypothesized that occipital neurostimulator (ONS) leads placed with ultrasonography combined with fluoroscopy would demonstrate increased survival rates and times when compared to ONS leads placed with fluoroscopy alone. STUDY DESIGN: A 2-arm retrospective chart review. SETTING: A single academic medical center. METHODS: This retrospective chart review analyzed the procedure notes and demographic data of patients who underwent the permanent implant of an ONS lead between July 2012 and August 2015. Patient data included the diagnosis (reason for implant), smoking tobacco use, disability, and age. ONS lead data included the date of permanent implant, the imaging modality used during permanent implant (fluoroscopy with or without ultrasonography), and, if applicable, the date and reason for lead removal. A total of 21 patients (53 leads) were included for the review. Chi-squared tests, Fishers exact tests, 2-sample t-tests, and Wilcoxon rank-sum tests were used to compare fluoroscopy against combined fluoroscopy and ultrasonography as implant methods with respect to patient demographics. These tests were also used to evaluate the primary aim of this study, which was to compare the survival rates and times of ONS leads placed with combined ultrasonography and fluoroscopy versus those placed with fluoroscopy alone. Survival analysis was used to assess the effect of implant method, adjusted for patient demographics (age, smoking tobacco use, and disability), on the risk of lead explant. RESULTS: Data from 21 patients were collected, including a total of 53 ONS leads. There was no statistically significant difference in the lead survival rate or time, disability, or patient age with respect to the implant method with or without ultrasonography. There was a statistically significant negative effect on the risk of explant with regards to lead removal in smoking patients compared to non-smoking patients (hazard ratio 0.36). There was also a statistically significant difference in smoking tobacco use with respect to the implant method, such that a greater number of patients whose leads were placed with combined fluoroscopy and ultrasonography had a history of smoking (P = 0.048). LIMITATIONS: This study is a retrospective chart review that had statistically significant differences in the patient groups and a small sample size. CONCLUSION: This study assessed the survival rates and times of ONS leads placed with ultrasonography and fluoroscopy versus fluoroscopy alone. We did not observe an effect to suggest that the incremental addition of ultrasound guidance to fluoroscopy as the intraoperative imaging modality used during the permanent implant of ONS leads yields statistically significant differences in lead survival rate or time. Medical comorbidities, including age and smoking status, may play a role in determining the risk of surgical revision and should be considered in future studies. KEY WORDS: Neuromodulation, peripheral nerve stimulation, occipital nerve stimulation, occipital neuralgia, chronic daily headaches, ultrasonography.

An Unusually Large Carbuncle of the Temporofacial Region Demonstrating Remarkable Post-debridement Wound Healing Process: A Case Report.

Skin carbuncles are debilitating skin infections commonly seen in elderly patients with diabetes. These infections develop when a cluster of adjacent furuncles coalesce to form one inflammatory mass. While they commonly occur on the nape of the neck and back, rarer sites involving the face and head have been noted. Management of these rare sites is urgent because of the potential intracranial complications and the surgical outcome is often unsatisfactory due to associated facial scarring. Intraoral drainage is advocated to avoid this; however, when the carbuncle involves a larger area, debridement from the exterior is necessary. The resultant soft-tissue defect requires a skin graft or a flap for coverage, but this may still lead to an unsatisfactory cosmetic outcome. The authors report a case of a carbuncle involving an extensive area over the right temporofacial region, including its management and the remarkable post-debridement cosmetic outcome despite avoidance of plastic surgery techniques due to the patient's high risk associated with anesthesia.

Effectiveness of collagen/oxidised regenerated cellulose/silver-containing composite wound dressing for the treatment of medium-depth split-thickness skin graft donor site wounds in multi-morbid patients: a prospective, non-comparative, single-centre study.

Split-thickness skin grafting (STSG) is a widely used method in reconstructive surgery, but donor site wounds (DSWs) are often slow healing and painful. This prospective study evaluated the performance of a composite wound dressing containing collagen/oxidised regenerated cellulose in the treatment of medium-depth (0·4 mm) DSWs in 25 multi-morbid patients with chronic leg ulcers requiring STSG. The range of patients' ages was 44-84 years (mean 71·6 years) with DSW sizes ranging between 12 and 162 cm2 (mean 78 cm2 ). Comorbidities included anticoagulation therapy (15 patients), anaemia (11 patients), diabetes (6 patients) and methicillin-resistant Staphylococcus aureus (MRSA) ulcer colonisation (6 patients). The first dressing change was performed after 10 days. Complete reepithelialisation was observed between the 10th and 34th day (mean 17·2, median 14 days). Postoperative medium to strong bleeding occurred in only five patients (four with anticoagulation). Wound pain levels one day after harvesting were only moderate (range 0-1·5, mean 0·5, median 0·5 on a six-item scale). No wound infection was observed during the first dressing. The composite dressing used allowed for the fast healing of medium-depth DSWs with minimal or no postoperative pain and bleeding in older multi-morbid patients under anticoagulation treatment.

Syndrome of inappropriate antidiuretic hormone in a patient with leptomeningeal carcinomatosis.

BACKGROUND: Leptomeningeal carcinomatosis is a condition in which metastatic cancer cells infiltrate the meninges of the brain and spinal cord, progressing to also involve the cerebrospinal fluid. Incidence of leptomeningeal carcinomatosis arising from an esophageal cancer is particularly rare. CASE PRESENTATION: Here, we present a case report of a 76-year-old Caucasian man with a history of esophageal adenocarcinoma status-post chemoradiation followed by resection. He was admitted to our unit for intractable headache, nausea without emesis, anorexia, weakness, gait instability, delirium, syncope, and near syncope. Our diagnostic workup revealed leptomeningeal carcinomatosis and syndrome of inappropriate antidiuretic hormone. Our patient was treated with lumbar puncture for the headache, methotrexate for the leptomeningeal carcinomatosis, and table salt for the syndrome of inappropriate antidiuretic hormone. Despite our best efforts, our patient died 6 weeks posttreatment. CONCLUSIONS: Understanding the molecular pathogenesis of the development of syndrome of inappropriate antidiuretic hormone associated with leptomeningeal carcinomatosis from metastatic esophageal adenocarcinoma would help us to identify patients at risk and treat them accordingly.

Headache and the pseudotumor cerebri syndrome.

Pseudotumor cerebri syndrome (PTCS) refers to the primary and secondary disorders that cause elevated intracranial pressure without an intracranial mass lesion, ventriculomegaly, or central nervous system infection or malignancy. Headache is the most frequent symptom of PTCS, but there is considerable overlap between the headache features of raised intracranial pressure and the headache features of primary headache disorders. We review headache subtypes that occur in PTCS, non-headache features that help distinguish PTCS from other headache types, changes to the diagnostic criteria for PTCS with and without papilledema, and headache treatment strategies as they apply to PTCS.

The course of headache in idiopathic intracranial hypertension: a 12-month prospective follow-up study.

BACKGROUND AND PURPOSE: Our aim was to prospectively describe the course of headache during the first year of idiopathic intracranial hypertension (IIH). METHODS: Patients with newly diagnosed IIH were consecutively included from December 2010 to June 2013. Treatment according to standard guidelines was initiated. Headache history was obtained by headache diaries and standardized interviews performed at baseline and after 1, 2, 3 and 12 months. Parallel changes in papilledema were assessed by optical coherence tomography (OCT). All patients had comprehensive neuro-ophthalmological examinations including automated perimetry. RESULTS: Forty-four patients were included. Thirty-five patients completed the 12-month follow-up. Dramatic improvement in headache occurred within the first weeks after diagnosis. After 1 year, 15 patients reported no or only infrequent headache. However, 15 of the remaining 20 patients reported sustained chronic headache. Early age of onset and high diagnostic intracranial pressure (ICP) were associated with better headache outcome (≤1 headache days/month) after a year. Papilledema decreased rapidly within the first 2 months of diagnosis. After 1 year, OCT measures had normalized. Visual outcome was excellent in most patients. CONCLUSIONS: Although headache in 43% of patients responded well to ICP management, sustained long-term headache was seen in the remaining patients, despite resolution of papilledema. Headache in IIH may thus be attributed to more complex mechanisms than ICP elevation alone. High ICP and young age were associated with better headache outcome. Early treatment according to standard guidelines seems sufficient to ensure excellent visual outcome in the vast majority of patients.

[A view on the life course of the most prevalent headache disorders. Spontaneous course, remission, and persistence]. / Life-course-Betrachtung der häufigsten Kopfschmerzformen. Spontanverlauf, Remission und Persistenz.

Symptoms and signs of primary headache disorders can change during one's lifetime. Moreover, the impact and the frequency of attacks can fluctuate in an individual patient over time. Before puberty, boys and girls are equally affected; after puberty most headache disorders predominate in women. The treatment of primary headache disorders always has to take into consideration the severity and the frequency of headache attacks as well as the relevant comorbidities. Prophylactic headache treatment can modulate the course of primary headache disorders. Specific prophylactic treatment is the most important instrument for avoiding headache chronification caused by medication overuse. While primary headache disorders tend to improve in elderly patients, secondary headache disorders peak in elderly people. They are often a symptom of oncologic diseases, vascular disorders, or are linked to side effects of drugs that are prescribed more frequently in the elderly. The treatment and the prognosis of secondary headache disorders always depend on the underlying disease.

Efeitos da terapia manual na cefaleia do tipo cervicogênica: uma proposta terapêutica / Effects of manual therapy on cervicogenic headaches: a therapeutic approach

A coluna cervical é considerada como possível fonte de dor de cabeça, entretanto ainda existem algumascontrovérsias a respeito da fisiopatogênese, quadro clínico e tratamento. Objetivo: Proporum protocolo com abordagem multimodal para tratamento fisioterápico de pacientes com cefaleiacervicogênica e avaliar os efeitos deste protocolo em tais pacientes. Método: Trata-se deum estudo experimental não controlado, no qual 9 pacientes da Clínica Escola de Fisioterapia doUNIFESO (Teresópolis, RJ) com diagnóstico de cefaleia cervicogênica foram submetidos a 10 intervençõesfisioterapêuticas com técnicas de terapia manual. O protocolo experimental incluiu técnicasarticulares, miofasciais e de recrutamento muscular. Como ferramentas de mensuração foramutilizadas a escala funcional Neck Disabilty Index (NDI), a escala visual analógica de dor (EVA) e oregistro do padrão do quadro álgico. Resultados: Dos 9 pacientes selecionados, todos eram dogênero feminino, e possuíam média de idade de 43,3 anos (± 15,5). Observou-se diferença entreas médias da intensidade do quadro álgico (EVA) antes do tratamento (8,0 ± 1,3) e após (2,2 ± 0,9;p < 0,01). O índice de incapacidade cervical também mostrou melhora após intervenção de 63,9%(p < 0,01). Em relação à frequência das crises semanais observa-se uma diminuição de 70% apósa intervenção (p < 0,01). De maneira similar, houve redução do tempo de permanência das crisesantes (4 horas ± 1,5) e após (1 hora ± 0,5) (p < 0,01). Conclusão: A abordagem multimodal pormeio de técnicas de terapia manual foi benéfica na redução do quadro sintomático dos pacientese ainda proporcionou diminuição do grau de incapacidade da região cervical.

The cervical spine is considered a possible source of headaches, however there are still some controversiesregarding the pathophysiology, clinical presentation, and treatment. Objective: To proposea physical therapy treatment protocol with multimodal approach for cervicogenic headacheand evaluate the effects of manual therapy on such patients. Method: This was an uncontrolledexperimental study in which 9 patients from the UNIFESO Physical Therapy Clinic (Teresópolis, RJ)diagnosed with cervicogenic headache underwent 10 physiotherapy interventions with manualtherapy techniques. The experimental protocol included joint techniques, fascial release, andmuscle recruitment. The Neck Disability Index (NDI) and a visual analogic scale (VAS) were used asmeasurement tools and the pain pattern was recorded. Results: Of the nine selected patients, allwere female and had an average age of 43.3 years (± 15.5). Significant differences were observedbetween the average intensity of pain (VAS) before treatment (8.0 ± 1.3) and after (2.2 ± 0.9,p < 0.01). The NDI also showed improvement after intervention 63.9% (p < 0.01). Regarding crisesfrequency, a decrease of 70% was observed after the intervention (p < 0.01) and a reduction wasalso shown in the duration of such crises before (4 hours ± 1.5) and after treatment (1 hour ± 0.5;p < 0.01). Conclusion: A multimodal approach by manual therapy techniques was beneficial in thereduction of the patients? symptoms and it provided a decrease in cervical disability.

A systematic review of peripheral nerve interventional treatments for chronic headaches.

OBJECTIVE: This study aimed to systematically compare the outcomes of different types of interventional procedures offered for the treatment of headaches and targeted toward peripheral nerves based on available published literature. BACKGROUND: Multiple procedural modalities targeted at peripheral nerves are being offered to patients for the treatment of chronic headaches. However, few resources exist to compare the effectiveness of these modalities. The objective of this study was to systematically review the literature to compare the published outcomes and effectiveness of peripheral nerve surgery, radiofrequency (RF) therapy, and peripheral nerve stimulators for chronic headaches, migraines, and occipital neuralgia. METHODS: A broad literature search of the MEDLINE and CENTRAL (Cochrane) databases was undertaken. Relevant studies were selected by 2 independent reviewers and these results were narrowed further by the application of predetermined inclusion and exclusion criteria. Studies were assessed for quality, and data were extracted regarding study characteristics (study type, level of evidence, type of intervention, and number of patients) and objective outcomes (success rate, length of follow-up, and complications). Pooled analysis was performed to compare success rates and complications between modality types. RESULTS: Of an initial 250 search results, 26 studies met the inclusion criteria. Of these, 14 articles studied nerve decompression, 9 studied peripheral nerve stimulation, and 3 studied RF intervention. When study populations and results were pooled, a total of 1253 patients had undergone nerve decompression with an 86% success rate, 184 patients were treated by nerve stimulation with a 68% success rate, and 131 patients were treated by RF with a 55% success rate. When compared to one another, these success rates were all statistically significantly different. Neither nerve decompression nor RF reported complications requiring a return to the operating room, whereas implantable nerve stimulators had a 31.5% rate of such complications. Minor complication rates were similar among all 3 procedures. CONCLUSIONS: Of the 3 most commonly encountered interventional procedures for chronic headaches, peripheral nerve surgery via decompression of involved peripheral nerves has been the best-studied modality in terms of total number of studies, level of evidence of published studies, and length of follow-up. Reported success rates for nerve decompression or excision tend to be higher than those for peripheral nerve stimulation or for RF, although poor study quantity and quality prohibit an accurate comparative analysis. Of the 3 procedures, peripheral nerve stimulator implantation was associated with the greatest number of complications. Although peripheral nerve surgery seems to be the interventional treatment modality that is currently best supported by the literature, better controlled and normalized high-quality studies will help to better define the specific roles for each type of intervention.