Cluster Attack

Narouze (2010) Role of Sphenopalatine Ganglion Neuroablation in the Management of Cluster Headache

Sick of taking pills or sucking down oxygen? From the Cleveland Clinic comes this review of one of the less invasive forms of surgery for cluster headache—sphenopalatine ablation.

Sphenopalatine Ganglion--The Cleveland Clinic Center for Medical Art & Photography

Cluster attacks originate in a small part of the brain in the center of the head called the hypothalamus, which controls (among other things) sleep, appetite, the autonomic nervous system, and the levels of various hormones. The autonomic nervous system is divided into two branches—the sympathetic (fight or flight) and the parasympathetic (rest and digest), both of which pass through the sphenopalatine ganglion, which is located at the back of the nose on both sides. Parasympathetic neurons synapse there, then run along with the maxillary nerve to the cheek and face. Sympathetic fibers pass through without synapsing and mainly end up in the walls of blood vessels. The sphenopalatine ganglion can be anaesthetized with drugs such as cocaine or lidocaine.
It can also be destroyed by heating it to 80 C for a minute with radiofrequency ablation. What happens to cluster headache when we do that?

Dr. Sanders in 1997 reported the following:

Episodic cluster headache (n=56): 60.7% complete relief
Chronic cluster headache (n=10): 30% complete relief

More recently, Dr. Narouze (who authored this article) had better luck. He performed sphenopalatine ablation on 15 chronic cluster headache patients then followed them for a    year and a half. Three (20%) experienced complete relief and were able to stop all medications. Seven (46.7%) converted from chronic cluster headache to episodic. Three (20%) noticed no change for a few weeks, then gradual improvement in the intensity and frequency of their attacks. Two (13%) had complete relief of their cluster headache—which unfortunately then came back on the other side. The only major complication of the procedure seems to be nosebleed.

What does this mean for medication-refractory chronic cluster headache patients? If you are considering surgery to treat your disease, then this has the advantage of being fairly minor compared to drilling a hole down to your hypothalamus. I am always skeptical of these peripheral procedures, however, because cluster headache is a central disorder. I have seen too many patients who had destructive surgery on one side of their head, only to have the cluster attacks squirt out on the other side instead—as happened to two patients in this series. As with any treatment, the risks and benefits need to be carefully weighed, and in this notoriously difficult crowd of refractory chronic cluster headache patients, Dr. Narouze seems to have obtained good results.

This entry was posted on Sunday, December 12th, 2010 at 5:09 am and is filed under Treatment. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.