Clinic-based Procedures for Headache.

PURPOSE OF REVIEW: Headache disorders are common and disabling, and many therapies that are effective and safe are procedural. RECENT FINDINGS: After pivotal clinical trials, onabotulinumtoxinA has become an established preventive therapy for chronic migraine; it is better tolerated than many other treatments and may be useful for other headache disorders. Peripheral nerve blocks, especially greater occipital nerve blocks, have amassed evidence from randomized trials in the acute and short-term preventive treatment of migraine and cluster headache. Trigger point injections and sphenopalatine ganglion blocks have recent trials suggesting efficacy and safety in properly selected patients. Medical education initiatives are needed to train neurologists in these procedures to help manage the large population of patients with headache disorders who need them. SUMMARY: Evidence exists for the efficacy and safety of procedural therapies to be incorporated into neurology practice for the management of patients with migraine, cluster headache, and other headache disorders.

Safety and efficacy of sphenopalatine ganglion stimulation for chronic cluster headache: a double-blind, randomised controlled trial.

BACKGROUND: Chronic cluster headache is the most disabling form of cluster headache. The mainstay of treatment is attack prevention, but the available management options have little efficacy and are associated with substantial side-effects. In this study, we aimed to assess the safety and efficacy of sphenopalatine ganglion stimulation for treatment of chronic cluster headache. METHODS: We did a randomised, sham-controlled, parallel group, double-blind, safety and efficacy study at 21 headache centres in the USA. We recruited patients aged 22 years or older with chronic cluster headache, who reported a minimum of four cluster headache attacks per week that were unsuccessfully controlled by preventive treatments. Participants were randomly assigned (1:1) via an online adaptive randomisation procedure to either stimulation of the sphenopalatine ganglion or a sham control that delivered a cutaneous electrical stimulation. Patients and the clinical evaluator and surgeon were masked to group assignment. The primary efficacy endpoint, which was analysed with weighted generalised estimated equation logistic regression models, was the difference between groups in the proportion of stimulation-treated ipsilateral cluster attacks for which relief from pain was achieved 15 min after the start of stimulation without the use of acute drugs before that timepoint. Efficacy analyses were done in all patients who were implanted with a device and provided data for at least one treated attack during the 4-week experimental phase. Safety was assessed in all patients undergoing an implantation procedure up to the end of the open-label phase of the study, which followed the experimental phase. This trial is registered with ClinicalTrials.gov, number NCT02168764. FINDINGS: Between July 9, 2014, and Feb 14, 2017, 93 patients were enrolled and randomly assigned, 45 to the sphenopalatine ganglion stimulation group and 48 to the control group. 36 patients in the sphenopalatine ganglion stimulation group and 40 in the control group had at least one attack during the experimental phase and were included in efficacy analyses. The proportion of attacks for which pain relief was experienced at 15 min was 62·46% (95% CI 49·15-74·12) in the sphenopalatine ganglion stimulation group versus 38·87% (28·60-50·25) in the control group (odds ratio 2·62 [95% CI 1·28-5·34]; p=0·008). Nine serious adverse events were reported by the end of the open-label phase. Three of these serious adverse events were related to the implantation procedure (aspiration during intubation, nausea and vomiting, and venous injury or compromise). A fourth serious adverse event was an infection that was attributed to both the stimulation device and the implantation procedure. The other five serious adverse events were unrelated. There were no unanticipated serious adverse events. INTERPRETATION: Sphenopalatine ganglion stimulation seems efficacious and is well tolerated, and potentially offers an alternative approach to the treatment of chronic cluster headache. Further research is need to clarify its place in clinical practice. FUNDING: Autonomic Technologies.

Prevalence and factors associated with the use of primary headache diagnostic criteria by chiropractors.

Background: The diagnosis of primary headaches assists health care providers in their decision-making regarding patient treatment, co-management and further evaluation. Chiropractors are popular health care providers for those with primary headaches. The aim of this study is to examine the clinical management factors associated with chiropractors who report the use of primary headache diagnostic criteria. Methods: A cross-sectional survey was distributed between August and November 2016 to a random sample of Australian chiropractors who are members of a practice-based research network (n = 1050) who had reported 'often' providing treatment for patients with headache disorders to report on practitioner approaches to headache diagnosis, management, outcome measures and multidisciplinary collaboration. Multiple logistic regression was conducted to assess the factors that are associated with chiropractors who report using International Classification of Headache Disorders (ICHD) primary headache diagnostic criteria. Results: With a response rate of 36% (n = 381), the majority of chiropractor's report utilising ICHD primary headache diagnostic criteria (84.6%). The factors associated with chiropractors who use ICHD primary headache diagnostic criteria resulting from the regression analysis include a belief that the use of ICHD primary headache criteria influences the management of patients with primary headaches (OR = 7.86; 95%CI: 3.15, 19.60); the use of soft tissue therapies to the neck/shoulders for tension headache management (OR = 4.33; 95%CI: 1.67, 11.19); a belief that primary headache diagnostic criteria are distinct for the diagnosis of primary headaches (OR = 3.64; 95%CI: 1.58, 8.39); the use of headache diaries (OR = 3.52; 95%CI: 1.41, 8.77); the use of ICHD criteria improves decision-making regarding primary headache patient referral/co-management (OR = 2.35; 95%CI: 1.01, 5.47); referral to investigate a headache red-flag (OR = 2.67; 95%CI: 1.02, 6.96) and not referring headache patients to assist headache prevention (OR = 0.16; 95%CI: 0.03, 0.80). Conclusion: Four out of five chiropractors managing headache are engaged in the use of primary headache diagnostic criteria. This practice is likely to influence practitioner clinical decision-making around headache patient management including their co-management with other health care providers. These findings call for a closer assessment of headache characteristics of chiropractic patient populations and for further enquiry to explore the role of chiropractors within interdisciplinary primary headache management.

Chronic Headache: a Review of Interventional Treatment Strategies in Headache Management.

PURPOSE OF THE REVIEW: To provide an overview of current interventional pain management techniques for primary headaches with a focus on peripheral nerve stimulation and nerve blocks. RECENT FINDINGS: Despite a plethora of treatment modalities, some forms of headaches remain intractable to conservative therapies. Interventional pain modalities have found a niche in treating headaches. Individuals resistant to common regimens, intolerant to pharmaceutical agents, or those with co-morbid factors that cause interactions with their therapies are some instances where interventions could be considered in the therapeutic algorithm. In this review, we will discuss these techniques including peripheral nerve stimulation, third occipital nerve block (TON), lesser occipital nerve block (LON), greater occipital nerve block (GON), sphenopalatine block (SPG), radiofrequency ablation (RFA), and cervical epidural steroid injections (CESI). Physicians have used several interventional techniques to treat primary headaches. While many can be treated pharmacologically, those who continue to suffer from refractory or severe headaches may see tremendous benefit from a range of more invasive treatments which focus on directly inhibiting the painful nerves. While there is a plethora of evidence suggesting these methods are effective and possibly durable interventions, there is still a need for large, prospective, randomized trials to clearly demonstrate their efficacy.

Neck-tongue syndrome.

Neck-tongue syndrome (NTS) is a rarely reported disorder characterised by paroxysmal episodes of intense pain in the upper cervical or occipital areas associated with ipsilateral hemiglossal dysaesthesia brought about by sudden neck movement. The most likely cause of this clinical entity is a temporary subluxation of the lateral atlantoaxial joint with impaction of the C2 ventral ramus against the articular processes on head rotation. NTS is an under-recognised condition that can be debilitating for patients and challenging for the treating physicians. Here, we report a 47-year-old man who fulfilled the International Classification of Headache Disorders, third edition criteria for a diagnosis of NTS was treated successfully with a chiropractic approach. There are currently no consensus guidelines for dealing with this disorder. Reassuringly, chiropractic care for uncomplicated NTS appears highly effective.

A meta-analytic study of experimental and chronic orofacial pain excluding headache disorders.

Chronic orofacial pain (COFP) disorders are prevalent and debilitating pain conditions affecting the head, neck and face areas. Neuroimaging studies have reported functional and grey matter abnormalities, but not all the studies have reported consistent findings. Identifying convergent abnormalities across COFPs provides a basis for future hypothesis-driven research aimed at elucidating common CNS mechanisms. Here, we perform three coordinate-based meta-analyses according to PRISMA guidelines to elucidate the central mechanisms of orofacial pain disorders. Specifically, we investigated consistent patterns of: (1) brain function to experimental orofacial pain in healthy subjects, (2) structural and (3) functional brain abnormalities in COFP. We computed our coordinate-based meta-analyses using GingerALE. The experimental pain meta-analysis revealed increased brain activity in bilateral thalami, posterior mid-cingulate cortices, and secondary somatosensory cortices, the right posterior parietal cortex extending to the orofacial region of the right primary somatosensory cortex and the right insula, and decreased activity in the right somatomotor regions. The structural COFP meta-analysis identified consistent higher grey matter volume/concentration in the right ventral thalamus and posterior putamen of COFP patients compared to healthy controls. The functional COFP meta-analysis identified a consistent increase in brain activity in the left medial and posterior thalamus and lesser activity in the left posterior insula in COFP, compared to healthy controls. Overall, these findings provide evidence of brain abnormalities in pain-related regions, namely the thalamus and insula, across different COFP disorders. The convergence of thalamic abnormalities in both structure and function suggest a key role for this region in COFP pathophysiology.

Long-term follow up of intractable chronic short lasting unilateral neuralgiform headache disorders treated with occipital nerve stimulation.

Background Occipital nerve stimulation is a potential treatment option for medically intractable short-lasting unilateral neuralgiform headache attacks. We present long-term outcomes in 31 patients with short-lasting unilateral neuralgiform headache attacks treated with occipital nerve stimulation in an uncontrolled open-label prospective study. Methods Thirty-one patients with intractable short-lasting unilateral neuralgiform headache attacks were treated with bilateral occipital nerve stimulation from 2007 to 2015. Data on attack characteristics, quality of life, disability and adverse events were collected. Primary endpoint was change in mean daily attack frequency at final follow-up. Results At a mean follow-up of 44.9 months (range 13-89) there was a 69% improvement in attack frequency with a response rate (defined as at least a 50% improvement in daily attack frequency) of 77%. Attack severity reduced by 4.7 points on the verbal rating scale and attack duration by a mean of 64%. Improvements were seen in headache-related disability and depression. Adverse event rates were favorable, with no electrode migration or erosion reported. Conclusion Occipital nerve stimulation appears to offer a safe and efficacious treatment for refractory short-lasting unilateral neuralgiform headache attacks with significant improvements sustained in the long term. The procedure has a low adverse event rate when conducted in highly specialised units.

Long-term outcomes of occipital nerve stimulation for chronic migraine: a cohort of 53 patients.

BACKGROUND: Chronic migraine affects up to 2 % of the general population and has a substantial impact on sufferers. Occipital nerve stimulation has been investigated as a potentially effective treatment for refractory chronic migraine. Results from randomised controlled trials and open label studies have been inconclusive with little long-term data available. METHODS: The long-term efficacy, functional outcome and safety of occipital nerve stimulation was evaluated in an uncontrolled, open-label, prospective study of 53 intractable chronic migraine patients. RESULTS: Fifty-three patients were implanted in a single centre between 2007 and 2013. Patients had a mean age of 47.75 years (range 26-70), had suffered chronic migraine for around 12 years and had failed a mean of 9 (range 4-19) preventative treatments prior to implant. Eighteen patients had other chronic headache phenotypes in addition to chronic migraine. After a median follow-up of 42.00 months (range 6-97) monthly moderate-to-severe headache days (i.e. days on which pain was more than 4 on the verbal rating score and lasted at least 4 h) reduced by 8.51 days (p < 0.001) in the whole cohort, 5.80 days (p < 0.01) in those with chronic migraine alone and 12.16 days (p < 0.001) in those with multiple phenotypes including chronic migraine. Response rate of the whole group (defined as a >30 % reduction in monthly moderate-to-severe headache days) was observed in 45.3 % of the whole cohort, 34.3 % of those with chronic migraine alone and 66.7 % in those with multiple headache types. Mean subjective patient estimate of improvement was 31.7 %. Significant reductions were also seen in outcome measures such as pain intensity (1.34 points, p < 0.001), all monthly headache days (5.66 days, p < 0.001) and pain duration (4.54 h, p < 0.001). Responders showed substantial reductions in headache-related disability, affect scores and quality of life measures. Adverse event rates were favourable with no episodes of lead migration and only one minor infection reported. CONCLUSIONS: Occipital nerve stimulation may be a safe and efficacious treatment for highly intractable chronic migraine patients even after relatively prolonged follow up of a median of over 3 years.

Cluster headache attack remission with sphenopalatine ganglion stimulation: experiences in chronic cluster headache patients through 24 months.

BACKGROUND: Cluster headache (CH) is a debilitating headache disorder with severe consequences for patient quality of life. On-demand neuromodulation targeting the sphenopalatine ganglion (SPG) is effective in treating the acute pain and a subgroup of patients experience a decreased frequency of CH attacks. METHODS: We monitored self-reported attack frequency, headache disability, and medication intake in 33 patients with medically refractory, chronic CH (CCH) in an open label follow-up study of the original Pathway CH-1 study. Patients were followed for at least 24 months (average 750 ± 34 days, range 699-847) after insertion of an SPG microstimulator. Remission periods (attack-free periods exceeding one month, per the ICHD 3 (beta) definition) occurring during the 24-month study period were characterized. Attack frequency, acute effectiveness, medication usage, and questionnaire data were collected at regular clinic visits. The time point "after remission" was defined as the first visit after the end of the remission period. RESULTS: Thirty percent (10/33) of enrolled patients experienced at least one period of complete attack remission. All remission periods followed the start of SPG stimulation, with the first period beginning 134 ± 86 (range 21-272) days after initiation of stimulation. On average, each patient's longest remission period lasted 149 ± 97 (range 62-322) days. The ability to treat acute attacks before and after remission was similar (37 % ± 25 % before, 49 % ± 32 % after; p = 0.2188). Post-remission headache disability (HIT-6) was significantly improved versus baseline (67.7 ± 6.0 before, 55.2 ± 11.4 after; p = 0.0118). Six of the 10 remission patients experienced clinical improvements in their preventive medication use. At 24 months post insertion headache disability improvements remained and patient satisfaction measures were positive in 100 % (10/10). CONCLUSIONS: In this population of 33 refractory CCH patients, in addition to providing the ability to treat acute attacks, neuromodulation of the SPG induced periods of remission from cluster attacks in a subset of these. Some patients experiencing remission were also able to reduce or stop their preventive medication and remissions were accompanied by an improvement in headache disability.

[Diagnosis and treatment characteristics of head-wind sha in She medicine].

The diagnosis and treatment characteristics of head-wind sha in She medicine were analyzed and summarized. By visiting She-nationality villages and towns in Zhejiang province and Fujian province and interviewing hundreds of doctors of She medicine, the sha diagnosis, sha differentiation, experience and theory of treatment were arranged, and a comprehensive summary on theory and application of head-wind sha in She medicine such as pathogeny, name of disease, mechanism, diagnosis, differential diagnosis and treatment was made. It is believed that the methods of diagnosis and treatment in She medicine for head-wind sha could effectively enhance curative effect, safety and patients' quality of life, and the further research should be carried out.

Approach to chronic daily headache.

Chronic daily headaches (CDH) is a descriptive term used for patients who experience headaches on at least 15 days or more out of the month; for at least 3 months, irrespective of the underlying headache etiology. It is a syndrome that affects many people, usually with an underlying primary headache disorder, leading to a reduction in quality of life. The two most common underlying primary headaches are migraines and tension-type headaches. The prevalence is about 4%, and research is emerging on risk factors and comorbidities. The first step when approaching a patient with chronic daily headaches is to rule out secondary causes. Once that is done, the goal is to effectively reduce the days of headache through preventive treatment as well as complementary therapies. This also often involves limiting the use of abortive therapy to avoid medication-overuse headaches (MOH). The pathophysiology, although not fully understood, is thought to be related to central sensitization along with "neurogenic inflammation." Chronic daily headaches can be difficult to treat and at times require a tertiary specialized center.

Chronic daily headache: diagnosis and management.

Chronic daily headache is defined as the presence of a headache on 15 days or more per month for at least three months. The most common types of chronic daily headache are chronic migraines and chronic tension-type headaches. If a red flag for a secondary cause of headache is present, magnetic resonance imaging of the head should be performed. All patients should be asked about medication overuse, which can increase the frequency of headaches. Patients who overuse medications for abortive therapy for headache should be encouraged to stop the medications entirely and consider prophylactic treatment. Several prophylactic treatments for chronic daily headache can reduce headache frequency and severity, as well as improve overall quality of life. Nonpharmacologic treatments include relaxation techniques, cognitive behavior therapy, acupuncture, osteopathic manipulation, and cervical exercises. Pharmacologic therapies include amitriptyline, gabapentin, onabotulinumtoxinA, propranolol, tizanidine, topiramate, and valproate.

Diagnosis and treatment of headache in the ambulatory care setting: a review of classic presentations and new considerations in diagnosis and management.

Headaches represent the most common constellation of neurologic disorders and are a very common cause of morbidity, lost work time, and decreased quality of life among sufferers. In this article, the diagnostic features, workup, and treatment of common, nuanced, and difficult-to-diagnose headache conditions were addressed. The future will hold a number of changes, with respect to both the diagnosis and treatment of headache disorders. As the aging population continues to grow, primary care providers will need to become increasingly familiar with differentiating between benign primary and more serious secondary headache disorders and will need to be able to treat the headache disorders unique to the elderly. With respect to therapeutic options, the future for treatment of the various headache disorders is promising. With the rise in popularity of complementary medical practices, there is likely to be more research on the roles of acupuncture, herbal and alternative remedies, massage therapy, and mind-body techniques. Further, new research is suggesting that neurostimulation may be useful in certain chronic, intractable headache conditions. Finally, the pathophysiology of headache disorders is still poorly understood and there is great hope that better understanding of the underlying mechanics of headache might contribute to improved treatment modalities and better quality of life for patients.

Noninvasive pulsed radio frequency energy in the treatment of occipital neuralgia with chronic, debilitating headache: a report of four cases.

OBJECTIVE: To examine the effects of noninvasive pulsed radio frequency energy (PRFE) on recurrent migraine headache associated with occipital neuralgia. METHODS: Four patients who were receiving long-term treatment with repeated greater and lesser occipital nerve blocks (GLONBs) to control recurrent migraine resistant to other treatment underwent treatment with noninvasive PRFE at home as a substitute for GLONB treatment. PRFE was administered by the patient at home for 30 minutes twice daily through an applicator pad placed directly over the occiput and upper cervical spine. RESULTS: Three of four patients reported a decrease in frequency, severity, or both of nonprostrating and prostrating migraines compared with their baseline symptoms; one reported no change from baseline. Comparing PRFE results with those obtained after nerve blocks, three of four patients reported decreases in nonprostrating migraines, while two reported a decrease in prostrating migraines. One patient reported an increase in prostrating migraine frequency. Variable degrees of increased productivity, decreased opioid and nonopioid analgesic use, and decreased visits to urgent care clinics were noted. In two patients who had combined PRFE and GLONB, marked improvement was noted in all symptoms. CONCLUSIONS: Improvement in frequency of headaches was noted, especially when PRFE was combined with GLONB. Further study is warranted.

Activation of the brainstem but not of the hypothalamus in hemicrania continua without autonomic symptoms.

A 64-year-old woman presented with a 6-month history of right-sided continuous headache, without autonomic symptoms and complete response to indomethacin. Clinical examination and structural brain imaging were normal. A diagnosis of hemicrania continua (HC) was made. We sought to determine the brain structures active during the pain in a patient who met all of the diagnostic criteria for HC with the exception of autonomic symptoms. A brain positron emission tomography study was performed during pain, and completely pain-free after indomethacin administration. Comparing the pain with pain-free states, the region of the dorsal pons was significantly activated. There was no activation in the hypothalamus, as previously reported in HC with autonomic symptoms. Although definitive conclusions can not be drawn from a single observation, the lack of autonomic symptoms along with the absence of hypothalamic activation suggests that the clinical presentation may predict the pattern of brain activation in primary headache syndromes.

[Use of anesthesiological technologies in the complex treatment of cervicocranial pain syndromes].

Four hundred and eighty-four patients with pain syndromes of cervicocranial localization, such as migraine, exercise-induced headache, cervicogenic headache, trigeminal neuralgia, trigeminal neuropathy, and occipital neuralgia were observed. The patients were randomized by the type, intensity, and duration of the pain syndrome and subdivided into two subgroups in each of the study nosological entities. The patients from control groups received the conventional complex therapy including drug (nonsteroidal anti-inflammatory drugs, central myorelaxants, anticonvulsants, and antidepressants depending on the type of a pain syndrome) and non-drug (physiotherapy, massage, and therapeutic exercises) ones. The patients were examined before, during, and after a course of therapy and comprised neurological and neuroorthopedic examinations; pain rating by the visual-analogue and the rank scale, and neuroimaging and electrophysiologic techniques. Comparison of the results obtained in the respective subgroups has indicated that anesthetic modes and reflex exposures in the complex therapy is an effective and safe procedure for relieving pain in the head and neck. Medicinal blocks arrest pain at shorter notice, reduce the single and daily doses of the used drugs and, in some cases, avoid their administration, thus, preventing their side effects, improve the quality of life, and increase the social activity of patients with cervicocranial pain syndromes.

[Chronic daily headache in children and adolescents]. / Les céphalées chroniques quotidiennes de l'enfant et de l'adolescent.

Chronic daily headache (CDH) affects 2-4% of adolescent females and 0.8-2% of adolescent males. Chronic daily headache is diagnosed when headaches occur more than 4h/day, 15 headache days per month or more, over a period of 3 consecutive months, without an underlying pathology. It is manifested by severe intermittent, migraine-like headaches as well as by chronic baseline headaches. Both Silberstein-Lipton criteria and the second edition of the International Classification of Headache Disorders (ICHD) can be used to classify chronic daily headache in children and adolescents. Chronic daily headache is classified into four diagnostic categories: transformed (Silberstein-Lipton criteria)/chronic (ICHD) migraine, chronic tension-type headache, new daily persistent headache, and hemicrania continua. Children and adolescents with chronic daily headache frequently have sleep disturbance, pain at other sites, dizziness, medication-overuse headache, and a psychiatric comorbidity (anxiety and mood disorders). Chronic daily headache frequently results in school absence. Successful approaches to treatment include reassurance, education, use of preventative medication, avoidance of analgesics, and helping the child return to a functional daily routine and a regular school schedule.