Suboccipital Steroid Injections for Cluster Headache
A useful and well-tolerated preventive measure for cluster headache
Attacks of cluster headache (CH) are, arguably, the worst recurrent pain phenomenon known. The usual mainstay of preventive medication for episodic CH is a diminishing course of oral corticosteroids, together with an escalating dose of verapamil. However, systemic corticosteroid administration is associated with well-known adverse effects, and verapamil often needs to be employed at high doses, necessitating close electrocardiographic monitoring during dose escalation to prevent cardiac arrhythmias (Neurology 2007; 69:668). Therefore, a simple, effective transitional preventive measure is needed to bridge the gap between attack onset and effective attack control by conventional preventive treatments. Manipulation of the greater occipital nerve, both by local injection and by electrical stimulation (Pain 2006; 122:126 and Neurology 2009; 72:341), is therapeutically useful for alleviating pain in several primary headache disorders. Now, researchers have conducted a randomized trial of three local injections (separated by 2 3 days) of the steroid cortivazol in the suboccipital region, ipsilateral to the side of pain, versus placebo injection of saline in 43 patients with episodic or chronic CH.
Cortivazol was significantly more effective than placebo at reducing the frequency of individual CH attacks to a mean of two or fewer attacks per day immediately after the third injection (achieved in 95% vs. 55% of patients; P=0.012). Cortivazol was also significantly better at reducing the mean number of attacks per person and the mean sumatriptan dose per person between days 1 and 15 of the trial. The authors note that the high placebo response may have resulted in part from some participants coming to the natural conclusion of their bout or benefiting from conventional preventives. Adverse effects were minor and did not cause treatment discontinuation.
Comment: Despite the potential bias issues raised by the authors, this small, well-designed trial offers further evidence that suboccipital steroid injections have a useful adjunctive role as a well-tolerated preventive approach in cluster headache. This treatment should be considered part of routine transitional management of patients with episodic CH going into a bout, or of patients with chronic CH who need add-on pain relief.
Alex Nesbitt, BM, BCh, and Peter J. Goadsby, MD, PhD, DSc
Dr. Nesbitt is Research Fellow (Neurology), Surrey Sleep Research Centre, University of Surrey, U.K.
Published in Journal Watch Neurology October 18, 2011
Leroux E et al. Suboccipital steroid injections for transitional treatment of patients with more than two cluster headache attacks per day: A randomised, double-blind, placebo-controlled trial. Lancet Neurol 2011 Oct; 10:891. [Medline ® Abstract]