|Year : 2016 | Volume
| Issue : 2 | Page : 140-142
Conventional radiofrequency ablation of sphenopalatine ganglion for the treatment of cluster headache
Sudhindra Dharmavaram1, Asokan Kondappan2, Vijayanand Palanisamy1, Senthil Kumar Raju1
1 Sri Ramakrishna Pain Management Centre, Sri Ramakrishna Hospital, Coimbatore, Tamil Nadu, India
2 Department of Neurology, Sri Ramakrishna Hospital, Coimbatore, Tamil Nadu, India
|Date of Web Publication||18-Jul-2016|
Sri Ramakrishna Pain Management Centre, Sri Ramakrishna Hospital, 395, Sarojini Naidu Road, Siddhapudur, Coimbatore, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Cluster headache is a primary neurovascular unilateral headache associated with autonomic symptoms. The sphenopalatine ganglion plays an important role in the pathogenesis of this disorder. Although medications are the first line of treatment, percutaneous, and surgical interventions have been proposed to treat cluster headache. An attractive option is the radiofrequency ablation of the sphenopalatine ganglion for the treatment of cluster headache due to its relative safety and simplicity compared with other procedures.
Keywords: Cluster headache, radiofrequency ablation, sphenopalatine ganglion
|How to cite this article:|
Dharmavaram S, Kondappan A, Palanisamy V, Raju SK. Conventional radiofrequency ablation of sphenopalatine ganglion for the treatment of cluster headache. Indian J Pain 2016;30:140-2
|How to cite this URL:|
Dharmavaram S, Kondappan A, Palanisamy V, Raju SK. Conventional radiofrequency ablation of sphenopalatine ganglion for the treatment of cluster headache. Indian J Pain [serial online] 2016 [cited 2020 Jul 2];30:140-2. Available from: http://www.indianjpain.org/text.asp?2016/30/2/140/186473
| Introduction|| |
Cluster headache is a neurovascular headache characterized by unilateral distribution of pain and the associated cranial autonomic symptoms. Various drugs such as triptans, nonsteroidal anti-inflammatory drugs, dihydroergotamines, oxygen inhalation, lithium, octreotide, steroids, melatonin, and local anesthetics have been used as both aborting and prophylactic agents. We describe conventional radiofrequency (RF) ablation of the sphenopalatine ganglion as a treatment modality in a patient with cluster headache after an unsuccessful medical management trial. Although it has been described elsewhere, there is a paucity of literature on RF ablation of sphenopalatine ganglion for treatment of cluster headaches in India.
| Case Report|| |
A 68-year-old man presented to us with 1 month history of progressively increasing intensity of left-sided facial pain and headache. The intensity of pain was severe (verbal, numerical score [VNS] - 10/10), and it occurred at a similar time every day - around 10 pm. The pain was felt in the left temporal and frontal areas, and around the left eyeball. It was associated with ipsilateral lacrimation and nasal stuffiness. Each episode lasted 2-3 h. There was no history of aura, hallucinations, nausea, vomiting, photophobia, or phonophobia. The pain was debilitating and affected his activities of daily living and disturbed his sleep. There were no appreciable triggers. The patient was a chronic smoker (5-10 cigarettes for the last 30-40 years) and a social drinker. His medical history was insignificant, and he had no medical comorbidities.
His cognitive functions, cranial nerves, sensory, and motor examination were normal. Magnetic resonance imaging (MRI) of the brain revealed bilateral neurovascular conflict at the trigeminal root entry zone. Notwithstanding, the MRI findings a diagnosis of episodic cluster headache was made based on the clinical features. Initially, he was prescribed a course of carbamazepine, but due to severe adverse effects (sedation and dizziness interfering with work), he stopped it. High-flow oxygen inhalation was tried with only partial benefit. Other medications such as sumatriptan, ergotamine, and pregabalin were tried for 2 weeks with minimal or no pain relief.
He was offered a diagnostic left sided sphenopalatine block. Through an infrazygomatic approach and under fluoroscopic guidance, a sphenopalatine ganglion block was performed with 2 ml 2% lignocaine and 10 mg depot preparation of methylprednisolone using a 23G Quincke Babcock needle.
The patient was sent home, and he reported a pain-free period (average VNS 0-1/10) of 3 days after which the pain recurred. In view of the positive response - >50% reduction in pain and autonomic symptoms, and improvement in functional status - a sphenopalatine ganglion RF ablation was offered with the aim of attaining long-term pain relief.
Written informed consent was taken before the procedure. With the patient in supine position, a lateral view of the skull was obtained to visualize the pterygomaxillary fissure, and the entry point was marked. A 22G 10 cm RF with 5 mm exposed tip was used. After infiltrating skin and deeper tissues with local anesthetic, the RF cannula was introduced directing the needle slightly cranially and ventrally to advance the tip of the needle through the pterygomaxillary fissure into the pterygopalatine fossa [Figure 1]. The tip of the needle was advanced to lie adjacent to the lateral wall of the nose on anteroposterior view [Figure 2]. Sensory testing was done, and paresthesia at the root of the nose was obtained at 0.3 V. Patient was sedated with appropriate doses of propofol and fentanyl and two lesions, each lasting 90 s, were done at 80°C.
|Figure 1: Lateral view showing the needle (N) entering the pterygomaxillary fissure and being advance towards the pterygomaxillary fossa|
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|Figure 2: Anteroposterior view showing the final position of the tip of needle (N) at the lateral wall of the nose|
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Postprocedure, the patient, was discharged as per institutional protocol. Soon after the procedure, the duration and intensity of the headaches gradually decreased and stopped over 7 days. The patient was pain-free (VNS = 0-1/10) for 2 months. No adverse effects related to the procedure were observed both in the immediate postprocedure period and during the follow-up. At 2 and 6 months, he reported having fortnightly attacks of pain (VNS = 1-2/10) associated with mild tearing and nasal stuffiness, but it did not interfere with his functional status. Although the patient was advised to take tablet tramadol 50 mg when he had pain, the patient did not feel the necessity to take the tablet.
| Discussion|| |
Cluster headache is a primary neurovascular headache associated with typical cranial autonomic signs. The diagnostic criteria and classification of cluster headache are detailed by the International Classification of Headache Disorders - III criteria  as given in [Table 1].
The pathophysiology of cluster headache is closely linked with the sphenopalatine ganglion. Sphenopalatine ganglion is a large extracranial structure with both sympathetic and parasympathetic innervations. Cluster headache involves activation of parasympathetic outflow from the superior salivary nucleus through the sphenopalatine ganglion resulting in the autonomic features associated with cluster headache.  This makes it a main target for interventional pain medicine specialists to treat cluster headaches.
Although pharmacological therapy is the first line of management of cluster headaches, other interventional modalities are necessary in patients who are refractory to pharmacological therapy or cannot tolerate the adverse effects. Initial interventions were surgical removal of greater superficial petrosal nerves. These were later followed by both percutaneous and surgical interventions on the trigeminal nerve and ganglion. The first successful treatment of cluster headache by blocking the sphenopalatine ganglion was reported in 1933.  Alcohol neurolysis and surgical resection of sphenopalatine ganglion were proposed later. 
Results from studies assessing the efficacy of RF ablation of sphenopalatine ganglion for the treatment of cluster headache are encouraging. Up to 60% of patients with episodic cluster headache have reported complete pain relief over a follow-up period ranging from 12 to 70 months.  The results of this procedure are slightly less efficacious in patients with chronic cluster headache, with 46% of patients reporting improvement in their pain and functional status.  At present, the strength of evidence for sphenopalatine ganglion RF ablation for cluster headache is 2C+ (the procedure can be considered). 
Epistaxis, cheek hematoma, reflex bradycardia are some of the minor complications of sphenopalatine ganglion RF ablation. Temporary hypoesthesia of the palate, maxilla, and posterior pharynx are also known to occur.  Although pulsed RF ablation of sphenopalatine ganglion appears to be a safer option, there are only anecdotal reports of its application in cluster headache.
| Conclusion|| |
The prominent role of sphenopalatine ganglion in the pathophysiology of cluster headache makes it a convenient target in the treatment of cluster headache. RF ablation of the sphenopalatine ganglion appears to be a simple, cost-effective, and safe treatment for cluster headaches refractory to medical management. Well-designed studies are required to confirm its efficacy and safety compared with other modalities of treatment in the Indian scenario.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]