Procedural Interventions for Headache: Acute, Preventive, Office-Based & Consultative Duren Michael Ready, MD FAHS ADAAPM Director, Headache Clinic Baylor

Procedural Interventions for Headache:

Acute, Preventive, Office-Based & Consultative

Duren Michael Ready, MD FAHS ADAAPMDirector, Headache Clinic

Baylor Scott & White central [email protected]

Disclosures

• Family Physician• UCNS Certified in Headache Medicine• Advanced Diplomate American Academy Pain

Management• Meyers Briggs ISTJ

Objectives

• Acquire the knowledge of how to incorporate office based interventions for the acute and preventive treatment of headache.

• Identify what outpatient consultative services are available and when it is appropriate

for referral• And to make it worth your time

Limbic Influences in Migraine

• All Pain has meaning• The Sorrow that hath no vent in tears may

make organs weep— Henry Maudsley • (When) the mind is hurt the body cries out

Italian Proverb• The body remembers what the mind forgets–

J.L. Moreno

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Not All Pain is NociceptiveSan Francisco Spine study 1992Five childhood traumas: Loss of parent, emotional neglect, substance abuse, physical abuse, sexual abuseNo risk factors = 95% chance surgical cure1-2 risk factors = 73% chance surgical cure3 or more risk factors = 15% chance of a surgical cureIncreased incidence of Chronic Migraine in victims of

Sexual Abuse.

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Case 1

• 61yo H TBI /c LOC >30y HAs 25/30 days♂

• Primarily L sided /c N/V, Allodynia, Neck Pain• Sleep Non-restorative, Onset delayed 1 hour• Often awakens with headaches• No prior preventive meds. Uses APAP

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Office Procedures

• Lower Cervical Intramuscular Injections• Occipital Nerve Block• Supraorbital/Supratrochlear Block• Sphenopalatine Ganglion Block• Pericranial Bupivacaine Injections• OnabotulinumtoxinA

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Peripheral Nerve Blocks and Trigger Point Injections

No widely accepted agreement among headache specialist for optimal technique of injection

type, doses of anesthetic used, & injection regimens

Lower Cervical Intramuscular Injections

• Headache 10/06• 417 ED Pts / 1 yr• 65% relief in 15m• Repeat injection

brought additional relief

• Worsened HA in 1%

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Lower Cervical Intramuscular Injections

• 3mL bupivacaine 0.5%• 25g 1.5” / 27g 1.25”• 2-3cm lateral to the

spinous processes between C6 & C7

• AE /CI• Vasovagal, Neck

stiffness, usual injection risks

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Lower Cervical Intermuscular Injection




Occipital Nerve Block

Placebo-controlled, blinded trials -- Difficult to perform. No industry funding available to support large

studies on this treatment.

Majority of studies (esp. earlier ones), uncontrolled.

Recent prospective studies difficult to interpret.

Occipital Nerve Block112 pts /c "sustained headache syndrome” received 188 injection treatments.

Inclusion criteria ON tenderness -- Used as Injection landmark for injection

Lidocaine & Betamethasone

59 "vascular headache" (probably migraine), 85% resulted in headache relief for > 1 week 12% resulted in headache relief for <1 week.

Migraine/Migrainous response better than remaining study population

Occipital Nerve BlockONB 108pts various HA -- Effect of Symptomatic Medication Overuse (SMO)Inclusion criteria HA reproduction with ON palpation

Bupivacaine and methyprednisolone. 78% response rate reduction in pain

83% duration 6.6 weeks

All Headaches /s SMO 89% /c SMO 37%

Intractable Migraine /s SMO 61% /c SMO 50% - clinically ns


Thought that rapidly ↓ allodynia ONB renders HA susceptible to earlier ineffective treatments.

56% of pts with SMO responded to ONB similarly to non overusers /c response duration ~ 1.5 weeks


Analgesic effect typically lasts beyond the anesthesia duration producing pain relief for several weeks to months Prolonged effect thought to be neuromodulary

effect of on central afferent pathwaysPoint of Maximum tenderness or Fan like, or

Ridge


Evidence for addition of corticosteroids to LA for GON block strongest for cluster headache For pts who require repeated injectionsrecommended frequency is individualized

Once every 2-4 weeks if needed & pt had a good response

If steroids used injections should be performed no sooner than 3 months.

Peripheral Nerve Blocks Trigger Point Injections

Selection Criteria

May use ON tenderness to palpation (TTP) or reproduction of headache pain /c ON

pressure (RHPONP) as selection criteria for identifying appropriate patients. Only a clinical trial can produce a definitive answer but current evidence suggests that these selection criteria isn't necessary for cervicogenic or cluster headache.

Peripheral Nerve Blocks What to Inject?

Again no consensus – Local Anesthetics often mixedLidocaine 1-2%

– Advantage quicker onset of action & can be buffered (Lidocaine/Sodium Bicarb 9:1)

Bupivacaine 0.25 – 0.5%Both Amide-- less allergenic than Esther LA Typically 1.5 – 3.5mL per nerveInhibit nerve conduc tion by reversibly inhibiting Na+ channelsPreferen tially act on C-fibers & Aδ fibers that mediate pain.Methemoglobinemia has been reported with LA treatment

rarely with those used routinely for ONB


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• AEs & CIs• Prior hx of craniotomy over injection site• AEs primarily related to steroid- fat atrophy,

alopecia, pigment change• Vagal response – Happened to me X 4 in over

9000 blocks

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Peripheral Nerve Block Migraine/ Occipital Overlap

Significant Overlap between Migraine & Occipital Neuralgia48% of 383 migraineurs actually had migraine associated

Occipital Nerve Irritation 50 patients /c migraines associated with ON irritation

88% rendered HA free average of 32 day by unilateral injection of 4 mL 1% lidocaine and 160 mg methylprednisolone

Similarly, 87% of 86 patients /c occipital neuralgia rendered pain free for 31 days (average)

Sphenopalentine Ganglion Block

• Over 100 years old• Fell into disfavor• Reemerged in ‘80s• Patients may self

administer• Lidocaine• May use cannula

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Sphenopalentine Ganglion Block Devices

Allevio TIAN 360

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Sphenopalatine Ganglion Block

ICHD Chronic Migraine > 3 monthsCould remain on preventive meds if stable 41 subjects randomized 2:1 bupivacaine salineBiweekly SPG block X 6 weeks SPG block Treated irrespective of pain at time of visitMeasured: Pain, Activity, Mood, & Work Interference.HA reduction 5.7 day vs 1.9 @ 1 month

(similar to Onabot & topiramate)Study was underpowered – Limits conclusionsCollective data suggests potential disease modification

Pericranial Bupivacaine InjectionsRobert Kaniecki, MD University of Pittsburgh

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Pericranial Bupivacaine Injections

• 218 Subjects• 34 sites – 0.25% Bup• Q 12 weeks• 87.1% Female• Age – 40.4 years• Migraine for 18 .5 years• 21.4/28 days /c HA• 15.5 Severe HA days• 18.3 Treatment days

• 55.2 % > 50% reduction– 35.3% achieved by 4 wk

• ↓HA days 22.8d to 9d• ↓ Severe 15.9d to 6.1d• ↓ Treatment 18.1d to 7.9d

• 11.5% no response/LtFu

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OnabotulinumtoxinA

• Observed that cosmetic injections improved migraine• Studies inconsistent• PREEMPT protocol designed

– 31 fixed site/ 155 units (2:1 dilution) every 12 weeks– Chronic Migraine only

• Reduction 8.4 days / 119.7 hours a month in headache• 47% had >50% reduction in migraine frequency • Significant improvement on Quality of Life• Neck Pain 9%

OnabotulinumtoxinAInjection Site

Onabot Real World Impact

• 230 pts /p 2 series of Onabot injections – 59% reduction in Urgent care Clinic visits – 55% reduction in ED visits– 57% reductions in hospitalization

• Avg healthcare savings of $1200/pt• Study replicated & Presented @ AAN 2015– 31.9% reduction in ED visits– 52.2 % reduction in hospitalizations at 6 months.

Case 1 - 61yo H /c hx TBI♂

• Initial placed on Magnesium, Tizanidine• Placed B ONB• ↓ Freq 3/7 days, + Memantine (NMDA

receptor blocker)• @ 1 yr HAs 1/7 days mild• Severe HAs 1/60 days responds to ONB

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Our Patients Speak

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Consultative Procedures

Radiofrequency Ablation

Nonsurgical ablative PNS/CNS techniques includeNeurolytic Agents (alcohol, phenol, etc)Thermal (cold-cryoanalgesia) or (hot using RFA)

RFA advantages--long lasting results/precise placementThought that RF lesion will stop nociceptive (A-δ/C-fiber) CNS input /s effecting A-β motor/sensory fibers.Scar formation @ lesioned site usual fashion (tissue coagulation, mild-moderate acute inflammation, cell necrosis, fibrosis & collagen fibers deposition)Takes about 3 weeks to complete. Schwan cell basal lamina is preserved allowing future regeneration.

Radiofrequency Ablation

• Pulsed Radiofrequency• Short pulses of relatively high voltage is

applied near a neural tissue• Avoids a significant temperature rise

decreasing risk of nerve injury. • Should be more selective for C fiber

denervation and decreasing chances of sensory/motor deficits

RFA - Patient Selection

• Screen for psych issues- somatization disorders/drug dependency

• Failure of diagnostic block at the same site to produce good pain relief

• May decrease placebo effect with repeat diagnostic blocks

Radiofrequency Ablation Sphenopalatine Ganglion

Narouze et al reported favorable outcomes in intractable chronic cluster headache /c significant improvements in mean attack intensity/frequency up to 18 months. 7/10 reported a change in headache pattern- returning to episodic cluster pattern3 pts remained headache free & off meds for the duration of follow-up 18-24 months. 2 pts reported complete relief of their usual unilateral cluster symptoms & instead they developed a side shift /c episodic cluster on the contralateral side.

Radiofrequency Ablation Sphenopalatine Ganglion

Salar reported effects of radiofrequency lesion of the SPG ganglion in refractory cluster headache 56 pts /c episodic cluster headache & 10 pts /c chronic cluster headache were followed over a period of 12 to 70 monthsEpisodic cluster group 60.7% experienced complete pain

relief Chronic cluster group had a 30% complete pain reliefConcluded that RFA of the SPG may improve episodic cluster headache but not chronic cluster headache

RFA - Trigeminal Neuralgia

• Correct diagnosis, failed medical therapies, MRI in pts < 60yo

• Pts > 60 yo should fail a therapeutic medical trial• • RF trigeminal gangliolysis has several advantages• Recovery is quick • Pt is awake during the procedure• Appears that pain recurrence is less than with glycerol

rhizotomy• where the needle is guided to the medial portion of the

foramen ovale assisted with fluoroscopy.

RFA - Trigeminal Neuralgia

• RF 83% success rate, Neurectomies 51%, Alcohol blocks 42%

• RF pain recurrences 72 months. Neurectomy one month. alcohol block > 1 month

• RF 20-25% had pain recurrence within 15 years• RF also had highest AE paraaesthesias(3-23%),

dysesthesia (3-23%)• Considered treatment of choice for 1st time

surgical intervention

Spontaneous CSF – Low Pressure Headache

• May be congenital (Marfans, Ehlers-Danlos, autosomal dominant polycystic kidney disease, neurofibromatosis), traumatic or, degenerative (multi-level)

• Believed that final common pathway is altered distribution of craniospinal elasticity due to spinal loss of CSF

Diagnosis of CSF Hypovolumnia

• Cranial MRI – Generally 5 characteristic imaging features

• SEEPS mnemonic, – subdural fluid collections, – enhancement of the meninges, – engorgement of venous structures, – pituitary hyperemia, and – sagging of the brain

• MRI may also be normal

SIH/Low Pressure HeadacheClinical Presentation

• SIH grt orthostatic headache worst within 15 minutes upright. May take several hours or towards end of the day or with excertion

• Improvement typically with 15 – 30 minutes of laying down• Headaches Bilateral, may/may not throb, occipital or suboccipital

region.• Positional nature of the headache frequently diminishes over time. • Other Sxs may include neck pain or stiffness, nausea, and emesis. • Echoing,, feeling underwater, off balance,• With downward brain displacement may cause visual blurring,

diplopia, and facial numbness/pain/weakness. • Severe brain displacement implicated in decreased level of

consciousness due to diencephalic herniation, dementia, and Parkinsonism.

SIH/Low Pressure HeadacheClinical Presentation

• SIH grt orthostatic headache worst within 15 minutes upright. May take several hours or towards end of the day or with excertion

• Improvement typically with 15 – 30 minutes of laying down• Headaches Bilateral, may/may not throb, occipital or suboccipital

region.• Positional nature of the headache frequently diminishes over time. • Other Sxs may include neck pain or stiffness, nausea, and emesis. • Echoing,, feeling underwater, off balance,• With downward brain displacement may cause visual blurring,

diplopia, and facial numbness/pain/weakness. • Severe brain displacement implicated in decreased level of

consciousness due to diencephalic herniation, dementia, and Parkinsonism.

SIH/LP HA Epidural Blood Patch

Epidural Blood Patch txt of choice for individuals who fail conservative management Immediate effect related to volume replacement by compression of the dural sac (decreasing the volume of the container)Sealing of the dural defect, which may be delayed from the first one. Not uncommon to have a rapid response (1st mechanism), recurrence of symptoms (1 or 2 days)

Then gradual & often variable improvement over several days. Variability is, however, substantial.

SIH/LP HA Epidural Blood Patch

The efficacy of each EBP (SIH) is about 30%Previous EBP failure should not be taken as a signal that a subsequent EBP will fail. IndeedMany pts may require more than one EBP /c some requiring several.Seems to have a higher efficacy rate in LP LPHAOne study had good results from lumbar EBP

Pts premedicated /c acetazolamide 250 mg @ 18 & 6 hours prior to EBP

Pts at 30-degree Trendelenburg 1 hour prior to the EBP, during the procedure, & 24 hours post

procedure

References• Kapural L,Mekhail N, Radiofrequency Ablation for Chronic Pain Control. Curr Pain Headache Rpt 2001,

5:517-525• Cray DP, Bajwa Z11, Warfield CA: Facet block and neurolysis. In Interventional Pain Management.

Edited by Waldman S. Phila-delphia, PA: W.11. Saunders; 1996:446-483.• Taha JM, Tew JM: Treatment of trigeminal neuralgia by percu-taneous radiofrequency

rhizotomy. Neurosurg Clin North Am 1997, 8:31-39.• • Oturai AB, Jensen K, Eriksen ): Neurosurgery for trigeminal neuralgia: comparison of alcohol

block, neurectomy and radiofrequency coagulation. Clin I Pain 1996, 12:311-315.• Scrivani SI, Keith DA, Mathews ES, Kahan LB: Percutaneous stereotactic differential

radiofrequency thermal rhizotomy for the treatment of trigeminal neuralgia. Oral Maxillofacial Slog 1999, 57:104-111.

• Taha JM, Tew JM, Buncher CR: A prospective 15-year follow up of 154 consecutive patients with trigeminal neuralgia treated by percutaneous stereotactic radiofrequency thermal rhizot¬omy.1 Neurosurg 1995, 83:989-993.

Taha JM, Tew JM: Comparison of surgical treatments for trigeminal neuralgia: reevaluation of radiofrequency rhizotomy. Neurosurgery 1996, 38:865-871.

References• Headache 2013;53:437-446• Vincent M. Greater occipital nerve blockades in cer vicogenic headache. Funct

Neuro l 1998;13:78-79.• Bovim G, Sand T. Cerv icogenic headache, migraine without aura and tension-

type headache. Diagnostic blockade of greater occipital and supra-orbital nerves. Pain. 1992;51:43-48.

• Anthony M. Cervicogenic headache: Prevalence and response to local steroid therapy. Clin Exp Rheumatol 2000;18(suppl. 19):S59-S64.

• Tobin JA, Flitman SS. Occipital Nerve Blocks: Effect of Symptomatic Medication Overuse and Headache Type on Failure Rate. Submitted

• Anthony M. Headache and the greater occipital nerve. Clin Neurol Neuosurg . 1992;94:297-301.

• Barrett J, Harmon D, Loughnane F, et al. Local anesthetics. In: Barrett J, Harmon D, Loughnane F, et al, eds. Peripheral Nerve Blocks and Peri Operative Pain Relief. Edinburgh: Saunders; 2004:11- 18.

References

• Saadah HA, Taylor FB. Sustained headache syndrome associated with tender occipital nerve zones. Headache. 1987;27:201-205.

• Tobin JA, Flitman SS. Occipital nerve blocks: Effect of symptomatic medication overuse and headache type on failure rate. Headache. 2009;49: 1479-1485.

• Cady, R. K., Saper, J., Dexter, K., Cady, R. J. and Manley, H. R. (2015), Long-Term Efficacy of a Double-Blind, Placebo-Controlled, Randomized Study for Repetitive Sphenopalatine Blockade With Bupivacaine vs Saline With the Tx360® Device for Treatment of Chronic Migraine. Headache: The Journal of Head and Face Pain, 55: 529–542

• Headache 2010; 50:943 – 952

Documents

Procedural Interventions for Headache: Acute, Preventive, Office-Based & Consultative Duren Michael Ready, MD FAHS ADAAPM Director, Headache Clinic Baylor