Reviewing Interventional Treatments for Chronic Headache

Interventional pain modalities provide alternative analgesia in patients who are intolerant of pharmacologic agents, have comorbidities that require multiple medications, or have pain refractory to oral medications.

When chronic headaches and facial pain are complicated by comorbidities, polypharmacy, intolerance, or refractory pain, some clinicians are turning to interventional modalities to ease headache pain.1 Patients who cannot get relief with acute treatment were found to be 2 to 3 times more likely to transition to chronic migraine.2

Interventions to treat the most common types of primary headache — migraine, tension-type headache, and trigeminal neuralgia — include nerve blocks, decompression surgery, and steroid injections.1 Unlike oral pharmacotherapy, the interventions directly inhibit the painful nerves.1 The evidence base supporting the use of such interventions is still scant, leaving clinicians to rely on studies with small sample sizes and limited case reports.

Transnasal sphenopalatine ganglion block

A modality that is gaining interest is the use of transnasal sphenopalatine ganglion (SPG) block for migraine, cluster headache, and trigeminal neuralgia because it is not invasive.2 Neurologist Mohamed Binfalah, MD, ABPN, from the University Medical Center, King Abdullah Medical City, in Adliya, Bahrain, and colleagues tested the technique in 55 patients (mean age, 37.9 years; 72.7% women) with the use of a sphenopalatine catheter filled with 2 mL of 2% lidocaine administered via each nostril.2

A total of 70.9%, 78.2%, and 70.4% of patients reported being free of headache 15 minutes, 2 hours, and 24 hours, respectively, after the procedure.2 The great majority of patients (98.1%) reported feeling “very good” or “good” 2 and 24 hours after the intervention, as assessed with the Patient Global Impression of Change scale. Adverse events were mild and lasted less than 24 hours, but patients reported throat numbness, nausea (10.9%), dizziness (10.9%), vomiting (1.8%), and nasal discomfort (18.2%).2

 “I don’t believe we have clear guidelines on the proper timing for using interventions in headache management,” remarked Dr Binfalah. “Some experts recommend using these interventions for refractory cases, but I think that it is reasonable to use interventions such as SPG blocks early in specific circumstances such as acute migraines not responding to analgesics, status migrainosus, migraine in pregnancy, acute cluster headaches, and in patients with low compliance or specific contraindications for oral or injectable analgesics and prevention medications.”

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Peripheral nerve blocks

In a population that is often coping with polypharmacy, comorbidities, and cognitive decline, clinicians are often limited in their prescribing repertoire. Therefore, researchers sought to determine the efficacy of peripheral nerve blocks (PNBs) on headaches in people age ≥65 years.3 In this retrospective chart study, 64 patients (mean age, 71 years; 78% women; average, 23 headache days per month) who had chronic migraine, episodic migraine, trigeminal autonomic cephalalgia, or occipital neuralgia were enrolled. Most of the patients were taking at least 1 medication and nearly half had hypertension. Comorbidities in this cohort included hyperlipidemia, arthritis, depression, and anxiety.

During the 6-year study period, patients received an average of 4 PNB treatments. Many of the PNB consisted of local anesthetics injected into the bilateral greater and lesser occipital nerves and the auriculotemporal, supraorbital, or supratrochlear nerves. The most frequently used analgesic was 0.5% bupivacaine alone, followed by 0.5% bupivacaine and 40 mg methylprednisolone. Overall, 73% of patients reported headache relief; patients with chronic migraine achieved the best results, with 81% reporting treatment efficacy. Neither patients nor the clinicians reported any adverse events.