Can a stellate ganglion block help treat 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 standard treatment option for this condition. 1

What is a Stellate Ganglion Block?

A stellate ganglion block is a selective sympathetic blockade that affects one side of the head, neck, upper extremity, and upper thorax. The procedure involves:

• Injection of local anesthetic (typically bupivacaine) near the stellate ganglion at the C7 level
• Blocks sympathetic nerve signals to these regions
• Traditionally performed using a paratracheal approach, though ultrasound guidance is increasingly used 2

Efficacy for NDPH

Current evidence does not support the use of stellate ganglion blocks for NDPH:

• No high-quality studies demonstrate efficacy specifically for NDPH 1
• The American Headache Society and other professional organizations do not include SGB in their treatment recommendations for NDPH
• While some case reports suggest benefit for other headache disorders like migraine and cluster headache, these findings cannot be extrapolated to NDPH 3, 4

Risks and Complications

SGB carries significant risks that must be considered:

• Inadvertent intravascular injection (potentially life-threatening)
• Pneumothorax (reported in multiple cases)
• Recurrent laryngeal nerve block causing hoarseness
• Phrenic nerve block affecting breathing
• Accidental subarachnoid or epidural injection
• Horner's syndrome (ptosis, miosis, anhidrosis) - expected side effect
• Severe complications occur at a rate of approximately 1.7 per 1000 procedures 5

Recommended Treatment Approach for NDPH

Instead of SGB, the following evidence-based approaches should be considered:

1. Pharmacological management:

   • NSAIDs (ibuprofen 400-800mg or naproxen sodium 275-550mg)
   • Acetaminophen (1000mg) for those who cannot tolerate NSAIDs
   • Preventive medications based on headache phenotype (amitriptyline for tension-type features)
   • Topiramate with careful counseling about side effects 1

2. Non-pharmacological approaches:

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

3. Other interventional approaches with better evidence:

   • Greater occipital nerve blocks may be considered for short-term treatment if NDPH has migrainous features 1

Important Considerations

• NDPH is notoriously difficult to treat and often requires a multimodal approach
• Treatment should be directed at the predominant headache phenotype (migrainous, tension-type)
• Patients should be cautioned about interventional procedures with limited evidence like SGB
• The risks of SGB outweigh potential benefits given the lack of evidence specifically for NDPH

While some emerging research suggests SGB might help with other conditions involving sympathetic hyperactivity 6, there is simply not enough evidence to recommend it for NDPH at this time, especially considering the potential serious complications.