Interventional Management of Head and Face Pain: Nerve Blocks and Beyond

By Samer N. Narouze

From the Foreword, by Stewart J. Tepper, MD:

 

“Dr. Samer Narouze was the first Pain Management anesthesiologist specialist in the US to become Board-certified in Headache Medicine by the United Council of Neurologic Subspecialists (UCNS). It is therefore fitting that he decided to put together a textbook on blocks, interventions, injections, and neuromodulation possibilities in this integrated interdisciplinary area of treatment for head and facial pain…

 

“This constellation of authors and topics should offer a comprehensive roadmap for interventions to contemplate beyond conventional medications in both primary and secondary head and face pain disorders. The chapters are precise, concise, and immensely readable, and I am honored to have been offered the chance to introduce them and encourage my colleagues to read them.”

 

 

 This is the first book on interventional management of intractable, medically resistant head and face pain.  It is edited and written by world-class leaders in headache medicine and features practical presentations of the entire spectrum of procedures, from simple to complex.  Designed to help shorten the learning curve of practitioners who are beginning to use interventional headache procedures, it provides guidance in identifying patients who are appropriate candidates for this approach and includes a unique compilation of outcomes-based algorithms for different headache and face pain syndromes.

 

Neurologists, anesthesiologists, pain physicians, physiatrists, neurosurgeons, and interventional radiologists are the intended audience.

• Language: English
• Publisher: Springer
• Release date: Jul 16, 2014
• ISBN: 9781461489511

Book preview

© Springer Science+Business Media New York 2014

Samer N. Narouze (ed.)Interventional Management of Head and Face Pain10.1007/978-1-4614-8951-1_1

1. Headache Classifications and Medically Resistant Headaches

Alexander Feoktistov¹  

(1)

Department of Clinical Research, Diamond Headache Clinic, 1900 Chesnut St. Ste 205, Glenview, IL 60025, USA

Alexander Feoktistov

Email: [e-mail]

Introduction

Headaches have been known to humanity for centuries. The first headache notation can be found 6,000 years ago, and it was Hippocrates who first gave more or less detailed description of migraine [1]. He first defined headache as a disorder. He described unilateral location of pain during migraine and its association with vomiting. Hippocrates was also among the first who described the phenomenon of visual aura in migraine sufferers.

Later there was Aretaeus of Cappadocia (first century AD), who being a migraineur himself was able to describe his own headaches in much more detail. He described such migraine-associated symptoms as phonophobia and photophobia. He also added more details to the description of visual aura. Another significant contribution made by this ancient Greek physician was the development of first headache classification [2, 3]. Aretaeus of Cappadocia proposed to divide all headaches depending of pain location and other pain characteristics into three major categories: heterocrania, cephalea, and cephalalgia. Galen of Pergamon (second century AD) first proposed the pathophysiological mechanism of migraine development [4]. Our understanding of migraines and headaches in general was and still is constantly growing.

Headache Classification

The first headache classification was proposed by Aretaeus of Cappadocia in the first century AD. Since that time our headache knowledge has been expanding exponentially. We started to distinguish and became familiar not only with migraine headaches but also with tension-type headaches, cluster headaches, paroxysmal hemicranias, chronic and episodic headache forms, etc. Eventually, the need for a new, broader, more clinical, and more detailed classification has naturally emerged. What we now consider the first official classification of headache disorders was developed in 1988. It was proposed by the International Headache Society and represented our most current knowledge (for that time) in headache clinical presentation, etiology, and pathogenesis. Although this classification was very detailed and provided clinicians with clear guidelines for the diagnosis of a variety of disorders, it was not perfect. It was missing major headache categories that were already well described by the time this classification was developed, such as medication overuse headache. Another downside of the first classification was that some of the diagnostic criteria used were based on expert opinion and were lacking supporting research evidence and published data. Furthermore, considering that our headache understanding has been continuously growing in big part due to expanding and rapidly developing research activities, more details and therefore corrections surfaced. Thus, in 2004, the 2nd edition of the International Classification of Headache Disorders was born [5].

Although the headache disorders classification is very extensive and rather complex for the purpose of this book, this chapter will be focusing mainly on those primary headache disorders that frequently represent therapeutic challenges (Table 1.1).

Table 1.1

International Classification of Headache Disorders, 2nd edition

Migraine Headache

Migraine is the second most common headache disorder after tension headache. It affects 15 % of all female and about 5 % of males, with a female-to-male ratio of 3:1. Migraine’s highest prevalence rate falls into the most productive age groups between ages 25 and 55. Thus, economical impact of migraine is truly astronomical. The classification of migraine headaches is presented in Table 1.2.

Table 1.2

Migraine classification

Migraine usually presents as severe, unilateral, throbbing headache, lasting between 4 and 72 h, and it is usually associated with photo- and phonophobia and/or nausea or vomiting (Table 1.3).

Table 1.3

Diagnostic criteria of migraine without aura

Migraine may present with aura – focal, temporary, and fully reversible neurological phenomenon consisting of visual field disturbance (positive and/or negative scotomas, flashing lights, visual field distortion, zig-zag lines), paresthesias, focal weakness of one or both unilateral extremities, vertigo, confusion, and aphasia. Depending on the type of aura, migraine may be further subclassified into migraine with visual aura, hemiplegic migraine, basilar-type migraine, retinal migraine, etc. Determining the type of aura has substantial clinical significance since it will dictate treatment strategy.

Those patients who experience more than 15 migraine days per month for at least 3 months (and otherwise fulfilling diagnostic criteria for migraine headache as described above) should be diagnosed with chronic migraine.

Cluster Headache

Cluster headache is one of the trigeminal autonomic cephalalgias and is among the most severe pain syndromes. Patients with cluster headache frequently describe it as the most severe headache or pain in general that they have ever experienced. It used to be called suicide headaches since there were cases described when people committed suicides during intractable cluster attacks. Cluster headaches usually occur in cycles or clusters (hence the name of the headache) during which patients experience a series of stereotypical headaches (sometimes occurring up to 8 attacks per day), daily or every other day for a period of time (cluster) that may last up to several weeks or even months. After that the headache may spontaneously disappear for a few weeks, months, or even years. It is not uncommon for the headache to occur at nighttime, waking patients from a sound sleep. Another typical feature of cluster headache is the strictly unilateral location (usually retro- or supraorbitally) of the pain (it never switches sides during the same headache attack and very rarely may affect opposite side during consequent cluster cycles). The pain is comparatively short lasting with duration between 15 min and 3 h. The headache is also associated with ipsilateral lacrimation, conjunctival injection, nasal congestion, and/or ptosis (Table 1.4).

Table 1.4

Diagnostic criteria of cluster headache

Cluster headaches that occur from 1 week and up to a year yet, within that year, being separated by headache-free periods of time lasting more than one month are subcategorized as episodic cluster headaches, and those cluster headaches that occur regularly for at least 1 year either without any remissions or with remission lasting less than a month are called chronic cluster headaches [5].

Other Trigeminal Autonomic Cephalalgias

Other trigeminal autonomic cephalalgias include paroxysmal hemicranias (episodic and chronic forms) and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT syndrome). All of these trigeminal autonomic cephalalgias have common features: they are all comparatively short lasting (and specific duration of a separate headache attack is one of the major keys to the correct diagnosis) and are associated with one or several autonomic symptoms (Table 1.5).

Table 1.5

Comparative characteristics of trigeminal autonomic cephalalgias

Headache Treatment

Headache treatment has also been constantly changing, developing, and progressing. If we look back, the twentieth century would be the period of time during which the field of headache management progressed the most. Thus, in 1916 ergotamine was first introduced and proven to be effective, and later in 1928, the first placebo-controlled trial was conducted [6]. Few decades later, triptans became available and are still conquering the world of migraine abortive medications. Prophylactic methods of headache treatment were also developed mostly in the twentieth century. Currently, a large number of abortive (triptans, ergotamine-containing medications, NSAIDs, opioids, etc.), prophylactic (tricyclic antidepressants, anticonvulsants, beta-blockers, calcium channel blockers, etc.) medications are available. New medications are being developed. Yet, despite all the clinical progress in the field of headaches, there is still a large population of headache sufferers who can’t find suitable and effective treatment for their pain. And that group of patients includes not only chronic headache sufferers but also those who struggle with episodic yet incapacitating headache forms (cluster headaches, SUNCT syndrome, migraine, etc.) for which they cannot find an effective remedy. These patients are the most challenging and frustrating group to treat. In most cases, these patients have tried a variety of treatment options including majority of acceptable and accessible treatment modalities available today. These patients are usually referred to as difficult headache patients or patients with refractory headaches. Obviously, we need to use a different approach in managing these patients. There is growing data that demonstrates that interventional approaches might be extremely effective and easily deployed in these complicated cases. But what makes the situation more difficult is the lack of criteria that could be used to early recognize these patients and refer them to an appropriate level of care that would address their refractory headache problem using more advanced and perhaps more effective approaches including interventional ones.

Refractory Headache

So, who should be considered for interventional headache treatment? What are the criteria that would help physicians to identify these patients and refer them to interventional pain specialists in a timely manner? There are no officially recognized, unified, and organized criteria for refractory headaches at this point. Yet, in the past few years, several attempts to develop effective and clinically acceptable diagnostic criteria were made. They are not finalized yet but rather represent an important ground for further investigation and research. Most of the investigators agreed that patients with refractory headache should have failed acute and/or prophylactic methods of treatment and should bare a certain degree of disability related to intractable headaches.

In 2008, Schulman et al. proposed refractory migraine diagnostic criteria that included failure to not only prophylactic but also abortive medications [7, 8]. In the proposed criteria, authors defined refractory migraine as a primary headache that leads to decreased functionality and quality of life in general considering that patients have failed both acute and preventive medication trials. Prophylactic treatment failure should be considered if patients have failed at least two out of four preventive medication groups (beta-blockers, calcium channel blockers, antidepressants, and anticonvulsants), considering that patients were able to reach therapeutic doses and were taking it for at least 2 consecutive months (unless they were discontinued secondary to side effects).

According to the criteria, failed abortive medication trial should be considered if patients have failed both triptans and ergotamine-containing medications, as well as NSAIDs or any other complex analgesic.

In 2010 Silberstein et al. proposed to subcategorize all patients with intractable or refractory headaches into classes [9]. For example, patients who have failed two different classes of nonspecific abortive medications (such as NSAIDs and other simple analgesics) would be subcategorized as Class I or mild. Patients who have failed both triptans and ergotamine-containing medications should be subcategorized as Class II or moderate. And finally, those patients who have failed not only specialized medications (triptans and ergotamine-containing substances) but also opioids, dopamine agonists, and corticosteroids should be subcategorized as Class III or severe. Similar ideas were also developed regarding therapeutic failure of prophylactic medications. Medications that should be considered when assessing patient’s treatment history should include beta-blockers, verapamil, tricyclic antidepressants, valproic acid derivatives, topiramate, or a combination of any above-mentioned prophylactic agents with either gabapentin, NSAIDs, vitamins, and supplements such as vitamin B2 or CoQ10. Another important feature to consider while assessing patient with medically resistant headaches is the degree of disability. Depending on the number of medications failed, all patients should be subcategorized into four classes (mild, moderate, severe, and very severe). That division of patients into severity classes might be very helpful in guiding furthermore advanced treatment modalities that may range from simple referral to a specialist to deployment of sophisticated interventional and surgical techniques [9]. In general, patients subcategorized into Class III (severe) or Class IV (very severe) should be considered candidates for an interventional approach.

An interesting and very practical point in the proposed criteria is that in order to qualify for refractory migraine or, for that matter, any other types of intractable headache, patients don’t have to meet the criteria for chronic type of headache. And that is a clinically relevant point – patients may suffer from severe episodic but yet refractory headache that needs to be addressed in the same way as patients with chronic forms of intractable headaches.

Although these criteria were proposed to diagnose refractory migraine, they could be also extrapolated to other forms of refractory headaches – tension-type headache, cluster, new daily persistent headache, medication overuse headache, etc.

Refractory Headache Pathogenesis

The problem of refractory headaches is being drastically overlooked, and only few studies in the past few years were designed to investigate this challenging entity. We still don’t have a clear answer why some patients develop refractory headaches. There were studies designed to look into possible structural or functional abnormalities that might be contributing to headache’s refractoriness to treatment. Few changes were noted in patients with migraines. In one of the studies, higher iron content was noted in the periaqueductal gray matter (PAG) that is located in the midbrain and is responsible for descending modulation of pain [10, 11]. Functional brain imaging using positron emission tomography (PET scan) also reveals activation of PAG during an acute migraine attack [12, 13]. According to Raskin et al., migraine attack could be triggered by PAG stimulation [14]. Lack of central nervous system habituation mechanisms had also been demonstrated [15].

Other studies looked into genetic predisposition that may lead to refractory headache development. The fact that migraines are genetically predisposed is well known and widely accepted. Few genes that are involved in different types of migraine pathogenesis were identified: CACNA1A in patients with familial hemiplegic migraine type I, ATP1A2 gene in familial hemiplegic migraine type II, and recently reported mutation in SCN1A gene in patients with familial hemiplegic migraine type III [16–18].

Medication Overuse Headache (MOH)

Medication overuse involvement in the pathogenesis of refractory headaches had also emerged. The fact that medication overuse may lead to chronification or transformation of episodic form of a headache to a chronic from – medication overuse headache (MOH) is well established [19, 20]. We also know that drug overuse diminishes prophylactic medications’ effectiveness and the drug needs to be discontinued for therapy to be successful. Yet, new facts emerged demonstrating that in some cases, discontinuation of medications that were overused does not significantly affect clinical outcome [21]. More so, a randomized, double-blind, placebo-controlled study showed that topiramate might be effective in patients with chronic migraine and coexisting medication overuse [22]. Although medication overuse is one of the major aggravating and contributing factors to headache chronification, it should be first attempted to eliminate the existing medication overuse before classifying a headache as refractory or intractable.

Psychological predisposition to refractoriness is another interesting topic. It has been demonstrated that patients with medication overuse headaches and chronic headaches in general have certain psychological peculiarities. For instance, these groups of patients have higher rates of depression and anxiety occurrence, altered and less effective pain coping strategies, etc. These specifics, perhaps, may play a role in leading to the development of chronic headaches with and without medication overuse and possibly add to headaches’ refractoriness to treatment [23, 24].

Although all these findings are extremely valuable and significantly contribute to our understanding of headache’s etiology, pathogenesis, and treatment, they still appear to be nonspecific. None of the available findings, so far, can clearly answer the question: why are these patients so refractory to a well established therapies and what are supposed to be effective treatment solutions?

References

1.

Clifford FR. The history of migraine from Mesopotamian to Medieval times. Cephalalgia. 1995;15 Suppl 15:1–3.

2.

Adams F. The extant works of Aretaeus, the Cappadocian. London: New Sydenham Society; 1856.

3.

Critchley M. Migraine: from Cappadocia to queen square. In: Smith R, editor. Background to migraine. London: Heinemann; 1967. p. 16–21.

4.

Kuehn CG. Claudii Galeni opera omnia, vol. 12. Leipzig: Officina Car. Cnoblochii; 1826.

5.

Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders. 2nd edition. Cephalalgia. 2004;24 Supp 1:9–160.

6.

Tfelt-Hansen PC, Koehler PJ. History of the use of ergotamine and dihydroergotamine in migraine from 1906 and onward. Cephalalgia. 2008;28(8):877–86.PubMedCrossRef

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Schulman EA, Lake 3rd AE, Goadsby PJ, Peterlin B, Siegel S, Markley HG, et al. Defining refractory migraine and refractory chronic migraine: proposed criteria from the Refractory Headache Special Interest Section of the American Headache Society. Headache. 2008;48(6):778–82.PubMedCrossRef

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Schulman EA, Brahin EJ. Refractory headache: historical perspective, need, and purposes for an operational definition. Headache. 2008;48(6):770–7.PubMedCrossRef

9.

Silberstein S, Dodick D, Pearlman S. Defining the pharmacological intractable headache for clinical trials and clinical practice. Headache. 2010;50:1499–506.PubMedCrossRef

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Kruit MC, Launer LJ, Overbosch J, van Buchem MA, Ferrari MD. Iron accumulation in deep brain nuclei in migraine: a population-based magnetic resonance imaging study. Cephalalgia. 2009;29(3):351–9.PubMedCentralPubMedCrossRef

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Knight YE, Goadsby PJ. The periaqueductal grey matter modulates trigeminovascular input: a role in migraine? Neuroscience. 2001;106(4):793–800.PubMedCrossRef

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Denuelle M, Fabre N, Payoux P, Chollet F, Geraud G. Hypothalamic activation in spontaneous migraine attacks. Headache. 2007;47(10):1418–26.PubMed

13.

Matharu MS, Bartsch T, Ward N, Frackowiak RS, Weiner R, Goadsby PJ. Central neuromodulation in chronic migraine patients with suboccipital stimulators: a PET study. Brain. 2004;127(Pt 1):220–30.PubMedCrossRef

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Raskin NH, Hosobuchi Y, Lamb S. Headache may arise from perturbation of brain. Headache. 1987;27(8):416–20.PubMedCrossRef

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Wang W, Schoenen J. Interictal potentiation of passive oddball auditory event-related potentials in migraine. Cephalalgia. 1998;18(5):261–5.PubMedCrossRef

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Ophoff RA, Terwindt GM, Vergouwe MN, van Eijk R, Oefner PJ, Hoffman SM, et al. Familial hemiplegic migraine and episodic ataxia type-2 are caused by mutations in the Ca2+ channel gene CACNL1A4. Cell. 1996;87(3):543–52.PubMedCrossRef

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Dichgans M, Freilinger T, Eckstein G, Babini E, Lorenz-Depiereux B, Biskup S, et al. Mutation in the neuronal voltage-gated sodium channel SCN1A in familial hemiplegic migraine. Lancet. 2005;366:371–7.PubMedCrossRef

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Tournier-Lasserve E. Hemiplegic migraine, episodic ataxia type 2, and the others. Neurology. 1999;53:3–4.PubMedCrossRef

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Feoktistov A, Filatova E, Vein A. Abuse headache. Zh Nevrol Psikhiatr Im S S Korsakova. 1999;12:58–61.

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Warner J. Frequent migraine and migraine status without tension-type headaches: an unusual presentation of rebound headaches. Cephalalgia. 2003;23(4):309–13.PubMedCrossRef

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Olesen J, Bousser MG, Diener HC, Dodick D, First M, Goadsby PJ, et al. New appendix criteria open for a broader concept of chronic migraine. Cephalalgia. 2006;26(6):742–6.PubMedCrossRef

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Diener HC, Bussone G, Van Oene JC, Lahaye M, Schwalen S, Goadsby PJ. Topiramate reduces headache days in chronic migraine: a randomized, double-blind, placebo-controlled study. Cephalalgia. 2007;27(7):814–23.PubMedCrossRef

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Feoktistov A. Clinico-psychophysiological peculiarities of the patients with abuse headache. Monograph (dissertation for Ph.D. degree), Ministry of Public Health of Russian Federation, Moscow Medical Academy, Moscow; 2001. p. 1–168.

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Feoktistov A, Filatova E, Vein A. Psychophysiological characteristic of groups of patients with analgesic rebound headache. Zh Nevrol Psikhiatr Im S S Korsakova. 2002;10:13–7.

© Springer Science+Business Media New York 2014

Samer N. Narouze (ed.)Interventional Management of Head and Face Pain10.1007/978-1-4614-8951-1_2

2. Algorithms for the Diagnosis and Management of Head and Face Pain

Samer N. Narouze¹  

(1)

Center for Pain Medicine, Western Reserve Hospital, 1900 Twenty-Third Street, Cuyahoga Falls, OH 44223, USA

Samer N. Narouze

Email: [e-mail]

Email: [e-mail]

This chapter will review different proposed algorithms to guide practitioners to make a precise diagnosis and hence better utilize interventional management for common headaches and facial pain syndromes.

In intractable resistant headaches, patients usually benefit the most from a multidisciplinary approach incorporating physical therapy, pharmacotherapy, psychotherapy (biofeedback and relaxation therapy), and the judicious utilization of interventional pain management modalities (Figs. 2.1, 2.2, 2.3, 2.4, and 2.5).

A300615_1_En_2_Fig1_HTML.jpg

Fig. 2.1

Chronic migraine

A300615_1_En_2_Fig2_HTML.jpg

Fig. 2.2

Medications overuse headache (MOH)

A300615_1_En_2_Fig3_HTML.jpg

Fig. 2.3

Occipital headache

A300615_1_En_2_Fig4_HTML.jpg

Fig. 2.4

Cervicogenic headache

A300615_1_En_2_Fig5_HTML.jpg

Fig. 2.5

Trigeminal neuralgia

Part II

Nerve Blocks for Head and Face Pain

© Springer Science+Business Media New York 2014

Samer N. Narouze (ed.)Interventional Management of Head and Face Pain10.1007/978-1-4614-8951-1_3

3. Peripheral Nerve Block for the Management of Headache and Face Pain

Sherif Costandi¹  , John Costandi²  , Dmitri Souzdalnitski³   and Samer N. Narouze⁴  

(1)

Department of Pain Management, Cleveland Clinic, 9500 Euclid Ave, C-25, Cleveland, OH 44195, USA

(2)

Oral and Maxillofacial Surgery Department, Columbia University Medical Center, 630 W168th St, 7-232, New York, NY 10032, USA

(3)

Center for