Managing cluster headache with sphenopalatine ganglion stimulation: a review

Abstract

Cluster headache (CH) is a primary headache and considered as one of the worst pains known to man. The sphenopalatine ganglion (SPG) plays a pivotal role in cranial autonomic symptoms associated with pain. Lesioning procedures involving the SPG and experimental acute SPG stimulation have shown some degree of efficacy with regard to CH. A neuromodulation device, chronically implanted in the pterygopalatine fossa, has been specifically designed for acute on-demand SPG stimulation. In a pilot placebo-controlled study in 28 patients suffering from refractory chronic CH, alleviation of pain was achieved in 67.1% of full stimulation-treated attacks compared to 7% of sham stimulation-treated attacks (p<0.0001). Long-term results (24 months; 33 patients) confirmed the efficacy of SPG stimulation as an abortive treatment for CH attacks. Moreover, 35% of the patients observed a >50% reduction in attack frequency, suggesting that repeated use of SPG stimulation might act as a CH-preventive treatment. Globally, 61% of the patients were acute responders, frequency responders, or both, and 39% did not respond to SPG stimulation. The safety of SPG microstimulator implantation procedure was evaluated in a cohort of 99 patients; facial sensory disturbances were observed in 67% of the patients (46% of them being transient), transient allodynia in 3%, and infection in 5%. SPG stimulation appears as a promising innovative, efficient, and safe therapeutic solution for patients suffering from severe CH. It has shown its efficacy in aborting CH attacks compared to placebo stimulation, suggesting that it is particularly adapted for CH patients who are not sufficiently improved by abortive treatments such as sumatriptan and oxygen. However, further studies comparing SPG stimulation with standard abortive and/or preventive CH treatments will be necessary to define more precisely its place within the management of severe chronic and/or episodic CH.

Keywords: cluster headache; neuromodulation; primary headache; sphenopalatine ganglion; stimulation.

Figure 1

Schematic and magnified representation of the SPG anatomy within the PPF. Notes: 1: Sphenopalatine (pterygopalatine) ganglion. 2: Maxillary division of the trigeminal nerve (V2). 3: Posterior superior alveolar nerve. 4: Infra-orbital nerve. 5: Zygomatic nerve. 6: Nasal nerves. 7: Pharyngeal nerves. 8: Palatine nerves. Abbreviations: PPF, pterygopalatine fossa; SPG, sphenopalatine ganglion.

Figure 2

Principle of the Pulsante system (Autonomic Technologies, Redwood City, CA, USA) designed for acute on-demand stimulation of the SPG. Notes: (A) External programming hardware. The program software (1) allows the physician to test and program the neurostimulator parameters to customize stimulation for each patient. The remote controller (2) is a rechargeable handheld device used by the patient to activate the neurostimulator, and it is also used by the physician to communicate with the neurostimulator during programming sessions. (B) The miniaturized neurostimulator is implanted in the PPF to stimulate the SPG and is fixed by screws to the maxillary bone. (C) Activation of the stimulation by the patient to abort the CH attack by application of the remote controller against the patient’s cheek. Abbreviations: CH, cluster headache; PPF, pterygopalatine fossa; SPG, sphenopalatine ganglion.

Figure 3

Pre- and postoperative imaging. Notes: (A) Preoperative CT scan tridimensional reconstruction allowing to plan the implantation of the SPG stimulation device within the PPF. (B) Postoperative anteroposterior craniofacial radiograph showing the placement of the SPG stimulation device. Abbreviation: CT, computed tomography; PPF, pterygopalatine fossa; SPG, sphenopalatine ganglion.