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28-09-2011 | General practice | Article

Suboccipital steroid injections give rapid relief to patients with cluster headache


Free abstract

MedWire News: Suboccipital steroid injections (SSI) are effective for the transitional treatment of patients with episodic or chronic cluster headache, show results of a randomized trial.

The 43 patients in the study (15 with chronic and 28 with episodic cluster headache) were randomly assigned to receive three suboccipital injections, given 48-72 hours apart, of cortivazol 3.75 mg or placebo. Patients with episodic cluster headache were also started on oral verapamil, if they were not already taking it, and those with chronic cluster headache continued their usual prophylactic medications.

Anne Ducros (Lariboisière Hospital, Paris, France) and colleagues explain that three SSI of cortivazol 3.75 mg are equivalent to oral prednisone 187.5 mg.

"High doses of oral steroids are usually necessary to reduce attacks, with prednisone 60-100 mg given daily for at least 5 days, then decreased by 10 mg every day to a total dose of 450-950 mg," they write in The Lancet Neurology.

"Attacks often resume when oral steroids are tapered down, whereas such a rebound was not reported with SSI in our study or others. SSI probably therefore have a local effect through the greater occipital nerve."

At enrollment, all patients were having more than two cluster headache attacks per 24 hours. There was a large placebo effect, with 12 of 22 placebo-treated patients having an average of two or fewer attacks per 24 hours by the end of treatment. The researchers say this could be due to spontaneous resolution of the attacks, or to the effect of verapamil, or to regression to the mean.

Yet patients given cortivazol had a significantly greater response, with 20 of 21 patients having two or fewer daily attacks after treatment.

The total number of attacks over the first 15 days of study was 30.3 on average in placebo-treatment patients, but 10.6 in those given cortivazol, which was again a significant difference.

There were no serious adverse events, and the most common adverse events were injection-site pain and noncluster headache.

In an accompanying commentary, David Dodick (Mayo Clinic in Arizona, Phoenix, USA) said that "the injection strategy used in this study is somewhat cumbersome and time consuming; however, obviating the need for high-dose oral corticosteroids and the potential for substantial side-effects and systemic toxic effects is very advantageous and desirable."

He listed several remaining questions, including whether one injection could be as effective as three, and if additional local anesthetic could enhance the effect or give sufficient pain relief without the corticosteroid.

But Dodick stressed that "for patients with cluster headache (and for the doctors who care for them) safe and effective transitional therapies are very important," making the study findings "welcome news indeed."

By Eleanor McDermid

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