Chicago Cluster Headache: Treatment and Prevention

Are Sphenopalatine Ganglion Blocks Superior to standard drug regimens?
Cluster Headache treatment can be divided into treatment of acute attacks and prevention and treatment should also be divided.

Cluster headaches common symptoms include :
Sudden onset of pain,Frequently behind the eye (retro-orbital) and around the eye (periorbital)
Pain rapidly builds to a peak intensity over 10 to 15 minutes
Restlessness or agitation
Nasal congestion or fullness
Eyelid drooping (ptosis) or swelling
Red, swollen or watery eyes
Sweating of the head and neck

They are more common in males and typically begin in late 20’s to early thirties.

They are one of a group of disorders known as Trigeminal Autonomic Cephalgias. They have in common that they are autonomic in orgin and are mediated by the Trigeminal Nervous System.

The Sphenopalatine Ganglion also known as Meckel’s Ganglion or the PterygoPalatine Ganglion is the largest Parasympathetic ganglion of the head whick also includes sympathetic fibers and Trigeminal nerves that pass though it without synapse.

I have previously written on how SPG Blocks have successfully treated and prevented SUNCT (short-lasting unilateral neuralgiform headache with conjunctival injection and tearing) in conjunction with a neuromuscular orthotic to eliminate noxious input th the Trigeminal nervous system.

Another Trigeminal Autonomic Cephalgia is the Paroxysmal Hemicrania that an article in Curr Pain Headache Rep. 2014 Apr;18(4):407. doi: 10.1007/s11916-014-0407-6. The article discusses how Greater Occipital Nerve blocks and Sphenopalatine Ganglion Blocks can treat these headaches.

The mainstay of treatment for Cluster Headaches for many years has been Oxygen administration that frequently stops acute attacks, it is safe and frequently effective. Triptans are also frequently utilized for both acute attacks and as a preventive measure.

Verampamil, a Calcium Channel Blocker and Lithium have been shown to be effective for many patients in preventing attacks.

A recent article in Curr Neuropharmacol. 2015;13(3):304-23 titled “The Neuropharmacology of Cluster Headache and other Trigeminal Autonomic Cephalalgias.” does a review of most current treatments for acure attacks and prevention. (the entire PubMed abstract is copied below). It also discusses new methods of treatment such as neurostimulation.

Almost 100% of all headaches are mediated by the Trigeminal Nervous System. The TrigeminoCervical complex is primarily responsible for cervical and occipital headaches and the TrigeminoVascular System seem to be the primary for release of neurotransmitters and neuropeptides that cause vasodilation . CGRP or Calcitonin Gene Related Peptide is one of these that research is currently investigating.

Unfortunately some of the most effective treatments due not create windfall profits for drug companies and therefore do not receive significant funding for research.

The amazing results frequently seen by altering noxious neural input to the Trigeminal nerve with neuromusculr orthotics are left unfunded by both drug companies and the NIH.
The Sphenopalatine Ganglion Block has recently received more intrest as companies investigate the viability onf implantable stimulators of the Sphenopalatine Ganglion.

New devices are also coming on the market to do SPG Blocks including the Sphenocath, the TX#^) and the MIRx Treatment Protocols and the Allevio device.

The injections continue to be highly effective but the self administration with cotton tipped applicators is, by far, the most cost effective method and more importantly it gives patients the ability to use SPG Blocks as preventives and for acute treatment.

I teach courses to physicians and dentists it giving SPG Blocks and I routinely teach my patients to self administer blocks intranasally.

Curr Neuropharmacol. 2015;13(3):304-23.
The Neuropharmacology of Cluster Headache and other Trigeminal Autonomic Cephalalgias.
Costa A1, Antonaci F, Ramusino MC, Nappi G.
Author information
1National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, via Mondino 2, 27100 Pavia, Italy. alfredo.costa@mondino.it.
Abstract
Trigeminal autonomic cephalalgias (TACs) are a group of primary headaches including cluster headache (CH), paroxysmal hemicrania (PH) and short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT). Another form, hemicrania continua (HC), is also included this group due to its clinical and pathophysiological similarities. CH is the most common of these syndromes, the others being infrequent in the general population. The pathophysiology of the TACs has been partly elucidated by a number of recent neuroimaging studies, which implicate brain regions associated with nociception (pain matrix). In addition, the hypothalamic activation observed in the course of TAC attacks and the observed efficacy of hypothalamic neurostimulation in CH patients suggest that the hypothalamus is another key structure. Hypothalamic activation may indeed be involved in attack initiation, but it may also lead to a condition of central facilitation underlying the recurrence of pain episodes. The TACs share many pathophysiological features, but are characterised by differences in attack duration and frequency, and to some extent treatment response. Although alternative strategies for the TACs, especially CH, are now emerging (such as neurostimulation techniques), this review focuses on the available pharmacological treatments complying with the most recent guidelines. We discuss the clinical efficacy and tolerability of the currently used drugs. Due to the low frequency of most TACs, few randomised controlled trials have been conducted. The therapies of choice in CH continue to be the triptans and oxygen for acute treatment, and verapamil and lithium for prevention, but promising results have recently been obtained with novel modes of administration of the triptans and other agents, and several other treatments are currently under study. Indomethacin is extremely effective in PH and HC, while antiepileptic drugs (especially lamotrigine) appear to be increasingly useful in SUNCT. We highlight the need for appropriate studies investigating treatments for these rare, but lifelong and disabling conditions.

Curr Pain Headache Rep. 2014 Apr;18(4):407. doi: 10.1007/s11916-014-0407-6.
Paroxysmal hemicrania: an update.
Prakash S1, Patell R.
Author information
Abstract
Paroxysmal hemicrania (PH) is an underreported and underdiagnosed primary headache disorder. It usually begins in the third or fourth decade of life. The recent observations indicate that it is equally prevalent in both males and females. PH is characterized by severe, strictly unilateral head pain attacks that occur in association with ipsilateral autonomic features. The attacks in PH are shorter and more frequent compared with cluster headache (CH) but otherwise PH and CH have similar clinical features. The hallmark of PH is the absolute cessation of the headache with indomethacin. However, a range of drugs may show partial to complete relief in certain groups of patients. Neuromodulatory procedures, such as greater occipital nerve blockade, blockade of sphenopalatine ganglion and neurostimulation of the posterior hypothalamus, are reserved for refractory PH.