What is the role of a stellate ganglion block in treating New Daily Persistent Headache (NDPH)?

Stellate Ganglion Block for New Daily Persistent Headache (NDPH)

There is insufficient evidence to recommend stellate ganglion block (SGB) for the treatment of New Daily Persistent Headache (NDPH), and it should not be considered a first-line or routine treatment option for this condition.

Understanding NDPH and Treatment Approaches

New Daily Persistent Headache (NDPH) is a primary headache disorder characterized by:

• Daily, persistent headache with a distinct and clearly remembered onset
• Continuous headache without remission
• Often refractory to conventional headache treatments

Evidence for Stellate Ganglion Block in Headache Disorders

Current evidence regarding SGB for NDPH specifically is extremely limited. While examining related headache conditions:

1. For Post-Dural Puncture Headache (PDPH):

   • Evidence does not support routine use of sphenopalatine ganglion blocks to treat PDPH (evidence grade: I; level of certainty: low) 1
   • Greater occipital nerve blocks may be offered for certain PDPH cases, but not stellate ganglion blocks 1

2. For Idiopathic Intracranial Hypertension (IIH):

   • Greater occipital nerve blocks may be considered helpful by some, but there is a lack of evidence and consensus 1

3. For Migraine:

   • Greater occipital nerve block is suggested for short-term treatment of migraine (weak recommendation) 1
   • There is insufficient evidence for sphenopalatine ganglion block for chronic migraine 1

4. For Cluster Headache:

   • Limited evidence suggests sympathetic blocks may help some cluster headache patients 2
   • However, the VA/DoD guidelines suggest against implantable sphenopalatine ganglion stimulator for cluster headache (weak against) 1

Safety Considerations for Stellate Ganglion Block

If considering SGB despite limited evidence, be aware of potential complications:

• Severe complications occur at a rate of approximately 1.7 per 1000 blockades 3
• Potential complications include:
  • CNS complications including convulsions
  • Subarachnoid or high epidural blockade
  • Pneumothorax
  • Allergic reactions
  • Inadvertent intra-arterial or subarachnoid injection (potentially life-threatening) 3

Treatment Algorithm for NDPH

Instead of SGB, consider this evidence-based approach for NDPH:

1. First-line treatments:

   • Regular multimodal analgesia including acetaminophen and NSAIDs 1
   • Topiramate (has evidence for chronic migraine) 1
   • Lifestyle modifications (regular meals, adequate hydration, exercise, sleep hygiene) 1

2. Second-line treatments:

   • Other preventive medications used for chronic migraine (amitriptyline, gabapentin, valproate) 1
   • Physical therapy for tension-type, migraine, or cervicogenic headache components 1
   • Aerobic exercise or progressive strength training 1

3. For refractory cases:

   • Greater occipital nerve block (has better evidence than SGB) 1
   • Referral to headache specialist for consideration of additional therapies

Case Report Evidence

While a case report showed improvement in two migraine patients with bilateral SGB 4, this represents very low-quality evidence that cannot be generalized to NDPH patients. The report showed:

• Improvement in VAS pain scores from 7-8 to 3-4
• Improvement in MIDAS scores from 32-37 to 6
• Required multiple treatments (weekly or biweekly for a month, then monthly for 3 months)

Conclusion

Based on current evidence, stellate ganglion block should not be routinely considered for NDPH. Treatment should focus on evidence-based approaches for chronic headache disorders, with SGB reserved only for exceptional cases under specialist care after failure of standard therapies.