Is a stellate ganglion block effective for treating new daily persistent headache (NDPH)?

Stellate Ganglion Block for New Daily Persistent Headache

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 standard treatment option for this condition.

Understanding NDPH and Treatment Approaches

New daily persistent headache is a primary headache disorder characterized by:

• Daily, unremitting headache with a distinct and clearly remembered onset
• Persistent headache from onset with no significant remission
• Often refractory to conventional headache treatments

First-Line Treatment Options for NDPH

Based on current guidelines, treatment should follow these steps:

1. Pharmacological management:

   • NSAIDs such as ibuprofen (400-800 mg) or naproxen sodium (275-550 mg) 1
   • Acetaminophen (1000 mg) for patients who cannot tolerate NSAIDs 1
   • Migraine-specific medications (triptans) if the headache has migrainous features 1
   • Preventive medications based on the predominant headache phenotype:
     • Amitriptyline for tension-type features 1
     • Topiramate (with careful counseling about side effects and contraceptive interactions) 1

2. Non-pharmacological approaches:

   • Physical therapy for tension-type or cervicogenic features 1
   • Aerobic exercise or progressive strength training 1
   • Lifestyle modifications including regular meals, adequate hydration, sleep hygiene 1

Stellate Ganglion Block: Evidence Assessment

Current evidence regarding SGB for NDPH is extremely limited:

• No mention of SGB for NDPH in major headache management guidelines 1
• Limited case reports showing potential benefit in migraine 2, 3, but not specifically for NDPH
• SGB carries risks including:
  • Accidental intravascular injection 4
  • Pneumothorax
  • Recurrent laryngeal nerve block
  • Phrenic nerve block
  • Spinal or epidural injection

Alternative Nerve Blocks with Better Evidence

If considering interventional approaches:

• Greater occipital nerve block has weak recommendation for short-term treatment of migraine 1
• Non-invasive vagus nerve stimulation has evidence for episodic cluster headache 5

When to Consider SGB

SGB might only be considered in very specific circumstances:

• After failure of all conventional pharmacological treatments
• After failure of other nerve blocks with stronger evidence
• In patients with features suggesting sympathetic nervous system involvement
• As part of a comprehensive pain management strategy by specialists experienced with the procedure

Technical Considerations if SGB is Attempted

If SGB is attempted as a last resort:

• Should be performed under fluoroscopic guidance at C6 or C7 level 6, 4
• Modified approaches targeting the junction between the uncinate process and vertebral body may reduce vascular complications 4
• Careful patient selection and informed consent regarding limited evidence and potential complications 7

Conclusion

The evidence does not support SGB as a standard treatment for NDPH. Treatment should focus on established pharmacological and non-pharmacological approaches based on the predominant headache phenotype, with consideration of greater occipital nerve blocks before attempting SGB in refractory cases.