Experimental activation of the sphenopalatine ganglion provokes cluster-like attacks in humans

Schytz, Henrik Winther; Barløse, Mads; Guo, Song; Selb, Juliette; Caparso, Anthony; Jensen, Rigmor Højland; Ashina, Messoud

doi:10.1177/0333102413476370

Cited by 83 publications

(64 citation statements)

References 37 publications

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“…Even though the physiopathology of CH is still unknown, the hypothalamus is thought to be the generator of this disease because of its circadian and circannual periodicity and the activation of the posterior hypothalamus found in neuroimaging studies that were undertaken during the attacks. Furthermore, activation of the parasympathetic outflow from the superior salivary nucleus via the SPG is supposed, explaining the autonomic manifestations of CH and the likely role of the SPG at least in this aspect of the disease . Indeed, it was shown that low frequency (5 Hz) SPG stimulation could induce cluster‐like attacks with autonomic features.…”

Section: Discussionmentioning

confidence: 99%

“…According to the explanation of the authors, this induction may be due to the release of neurotransmitters from parasympathetic efferents, which activate or at least modulate trigeminal nociceptors. On the other hand, high frequency (80 to 120 Hz) SPG stimulation may activate sensory fibers from the maxillary nerve, which converge in the trigeminal nucleus caudalis with afferents from the ophthalmic branch, leading to antinociceptive modulatory changes . It is important since the pain of CH is thought to be due to activation of the ophthalmic nerve .…”

Section: Discussionmentioning

confidence: 99%

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Unsuccessful Pulsed Radiofrequency of the Sphenopalatine Ganglion in Patients with Chronic Cluster Headache and Subsequent Successful Thermocoagulation

2015

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We present the results of pulsed and continuous radiofrequency (CRF) of the sphenopalatine ganglion in a case series of 3 patients with chronic cluster headache (CCH). Three patients were referred to our neurosurgical department because of CCH, which was refractory to pharmacological treatment. They underwent pulsed radiofrequency of the sphenopalatine ganglion (PRF-SPG), and the procedure was performed through an infrazygomatic approach. In the PRF procedures, we applied 2 cycles of PRF at 42°C and 45 V for 120 seconds, with a pulse frequency of 2 Hz and a pulse width of 20 ms. In those procedures where thermocoagulation was carried out, 2 CRF lesions at 80°C for 90 seconds each were performed. Following corticosteroid and local anesthetic (40 mg of methylprednisolone and 1 mL of 1% lidocaine) injection, 2 patients had no pain relief at all, whereas the third one experienced a partial response, which lasted only 1 month and his pain then returned to its baseline level. Thus, this outcome was assessed as a nonsustained partial response. Therefore, all of them underwent a CRF lesioning of the SPG, and after this procedure, they achieved complete pain relief until the end of the follow-up period. Furthermore, the associated autonomic manifestations disappeared. The 3 patients presented in this case series failed to achieve adequate pain relief after PRF-SPG. However, these same patients subsequently underwent a successful CRF of the SPG.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Unsuccessful Pulsed Radiofrequency of the Sphenopalatine Ganglion in Patients with Chronic Cluster Headache and Subsequent Successful Thermocoagulation

2015

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“…These findings have led to several speculations on the possible mechanisms of action of SPG stimulation in aborting CH attacks. The authors suggested that the therapeutic effect of high frequency stimulation might be caused by physiological block of parasympathetic activity as a result of depletion of stored neurotransmitters [13].…”

Section: Sphenopalatine Ganglion Stimulationmentioning

confidence: 99%

Advanced technologies and novel neurostimulation targets in trigeminal autonomic cephalalgias

2015

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The trigeminal autonomic cephalalgias (TACs) are a group of rare but disabling primary headache disorders. Their management is challenging, since only few effective treatments are available and high doses may be required to control the headache, compromising patients' adherence to treatments. A significant minority of patients, who fail to respond to or tolerate established treatments, are left with enormous level of disability and disruption to their quality of life. A growing body of evidence demonstrates the efficacy of central and peripheral neuromodulation approaches for management of patients with refractory TACs. In view of the potential risks related to deep brain stimulation of the posterior hypothalamic region, occipital nerve stimulation is currently considered the first treatment option for refractory chronic TACs. However, in view of the presence of paraesthesia induced by the stimulator, no robust controlled trials have been possible so far. Additionally, the equipment used for occipital nerve stimulation is not designed specifically for peripheral nerve stimulation, thus a significant proportion of patients experience device-related complications that often require surgical revisions. To overcome these issues, new neurostimulation technologies using less invasive or non-invasive approaches and modulating different neuroanatomical targets have been recently studied.

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“…The SPG is located in the pterygopalatine fossa and contains parasympathetic and sympathetic fibers directly and indirectly connecting somatic and visceral nerve structures of the face to the trigeminovascular system, the superior salivatory nucleus in the brainstem and the hypothalamus. In cluster headache patients, low-frequency stimulation of the SPG can induce cluster-like attacks which can be aborted by high-frequency stimulation [26]. One proof of concept study found that in 6 patients, 11 out of 18 spontaneous or induced CH attacks were aborted by stimulating the SPG [27].…”

Section: Sphenopalatine Ganglion (Spg) Stimulationmentioning

confidence: 99%

Update on future headache treatments

Nagy

Rapoport

2013

Neurol Sci

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Headache disorders are common and heterogenous neurologic entities. The complexities of management are further encumbered by the relatively few effective choices for acute and preventive therapies available to the headache specialist to treat these diverse disorders. As advances have been made in uncovering headache pathophysiology, new therapies have surfaced and others are forthcoming. This article will highlight new lines of care in development. There are several novel delivery mechanisms of familiar medications which bypass the limitations of current delivery systems, including the sumatriptan iontophoretic patch Zecuity, the intranasal sumatriptan OptiNose system, the zolmitriptan Rapidfilm orally dissolvable film and the orally inhaled dihydroergotamine Levadex system. New lines of care based upon recently discovered therapeutic targets will also be discussed including calcitonin gene-related peptide (CGRP) receptor antagonists, serotonin receptor agonists, and sphenopalatine ganglion (SPG) intermittent stimulation. Finally, emerging targets for future therapeutics will be explored including transient receptor potential vanilloid (TRPV1) receptor modulators, nitric oxide (NO) antagonists, gap junction modulators, glutamate receptor antagonists, orexin receptor antagonists and prostanoid receptor antagonists. Therapies developing over the next several years will be welcome additions to the headache specialist's armamentarium.

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Experimental activation of the sphenopalatine ganglion provokes cluster-like attacks in humans

Cited by 83 publications

References 37 publications

Unsuccessful Pulsed Radiofrequency of the Sphenopalatine Ganglion in Patients with Chronic Cluster Headache and Subsequent Successful Thermocoagulation

Unsuccessful Pulsed Radiofrequency of the Sphenopalatine Ganglion in Patients with Chronic Cluster Headache and Subsequent Successful Thermocoagulation

Advanced technologies and novel neurostimulation targets in trigeminal autonomic cephalalgias

Update on future headache treatments

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