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

Abstract

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.

Sphenopalatine Ganglion Block in the Management of Chronic Headaches

“…These techniques have different mechanisms of action at the target site. Bendersky et al illustrated this when they published a case series in which three patients had partial relief with PRF but experienced complete symptom resolution with a subsequent RFA 2 months after their initial intervention with PRF [28].…”

Long‐term Outcomes of Computerized Tomography–Guided Sphenopalatine Ganglion–Targeted Pulsed Radiofrequency for Refractory Cluster Headache

“…Complete pain relief was observed in 2 patients with ECH and CCH, and the other patient with CCH received partial relief after the PRF procedure. In contrast, in 2015, Bendersky et al reported that SPG‐PRF under lateral fluoroscopy guidance was unsuccessful. Only 1 of 3 patients with CCH achieved PR after SPG‐PRF, and poor efficacy was shown in the other 2 patients.…”

“…Therefore, PRF is expected to be a first‐line treatment for patients with refractory CHs who have not responded to or cannot tolerate drug treatments. However, Bendersky et al counterargued that the efficacy of PRF for CCH is insufficient. Therefore, further studies are needed to evaluate whether SPG‐PRF is a promising treatment for CHs.…”

“…A few studies have reported the efficacy and safety of PRF for CHs in small populations, which is ascribed to the low morbidity of CH. Chua et al and Bendersky et al reported the outcomes of performing PRF on 3 patients with CHs. Our previous study reported the outcomes of 13 patients with ECH and 3 with CCH who underwent PRF as an alternative treatment.…”

Cluster headache management and beyond

“…Lastly, going beyond the actual management of CH, VNS seems to be promising but is still classified at Class IV evidence [21], while sphenopalatine ganglion stimulation shows contrasting evidence [29,30] that needs to be confirmed and validated through RCTs.…”