Supraorbital nerve stimulation in intractable chronic cluster headache

Supraorbital Nerve Stimulation

Abstract Title: Supraorbital nerve electric stimulation for the treatment of intractable chronic cluster headache

American Society of Regional Anesthesia & Pain Medicine - Spring 2007 Abstract Archives - Annual Spring Pain Meeting & Workshops

Authors: Narouze S¹, Narouze ²
Cleveland Clinic Foundation¹, Cleveland Clinic Foundation²
Poster Type: Either

ABSTRACT BODY

Introduction:

Cluster headache is a primary neurovascular headache. It is strictly unilateral head pain mainly in the ophthalmic distribution of the trigeminal nerve that is associated with cranial autonomic symptoms and usually has a circadian and circannual pattern.
There are 2 forms of cluster headache, episodic and chronic. Episodic cluster headache occurs in periods from 7 days to 1 year separated by pain-free periods ≥1 month. Chronic cluster headache occurs for more than one year with no or <1 month remission.1,2
Chronic cluster headache accounts for about 10% of patients with cluster headache and it usually lakes the circadian pattern and patients are often resistant to pharmacological management. 2

Case Report:

35-year-old male with h/o episodic cluster headache for the last 5 years. His headaches lost the circadian pattern and continued without remissions for the last 2 years. He has 2-3 attacks of classic cluster headaches per day, each lasts for 1½-2 hours. His attacks consist of excruciating right orbital and supraorbital pain associated with lacrimation, conjunctival injection, rhinorrhea, eyelid edema and ptosis. He became resistant to SC Sumatriptan,DHE, oxygen, and narcotics. He also failed multiple preventive pharmacological therapies including: verapamil, lithium, valproic acid, and topamax. Occipital nerves and sphenopalatine ganglion blocks didn’t give him any sustained relief. After appropriate psychological evaluation, he underwent a permanent implant(after a successful 7 days trial)of a percutaneous quadripolar electrode that was placed horizontally across the course of the supraorbital nerve just above the supraorbital ridge. The lead was tunneled and anchored behind the ear and then connected to the generator placed in the infraclavicular area. After the implant, the patient reported good coverage over the supraorbital area and the ability to terminate the cluster headache attacks in few minutes after turning on the stimulation. Also his headaches decreased in frequency to one attack ever other day. His cluster headache lasted for only 2 months after the implant and he is in remission for the last 6 months.

Discussion:

The pathophysiology of cluster headache involves ophthalmic division of trigeminal nociceptive activation with resulting reflex cranial parasympathetic autonomic activation.2
Our proposed theory is neuromodulation of the afferent input in the ophthalmic division of the trigeminal nerve by electric stimulation of the supraorbital nerve, the terminal cutaneous branch of the ophthalmic nerve, will interfere with the trigeminal-autonomic reflex and abort the attack of cluster headache.
Recently there is interest in applying peripheral nerve stimulation in the management of occipital neuralgia and other craniofacial pains.3
To our knowledge this is the first report to describe the effectiveness of supraorbital nerve stimulation in the management of cluster headaches. This is a relatively simple, minimally invasive and reversible modality of treatment that may be effective in the management of otherwise one of the most devastating headache that one can experience.

References:
1-Cephalalgia 2004; 24 (Suppl 1): 1-160
2-Lancet Neurology 2002; 1:251-257
3-Neuromodulation 2005; 8:7-13

Reprinted with permission of the American Society of Regional Anesthesia & Pain Medicine http://www.asra.com/

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Page Last Updated: 06/21/2007