{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,6]],"date-time":"2026-06-06T02:15:06Z","timestamp":1780712106400,"version":"3.54.1"},"reference-count":46,"publisher":"BMJ","issue":"2","license":[{"start":{"date-parts":[[2023,11,20]],"date-time":"2023-11-20T00:00:00Z","timestamp":1700438400000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Reg Anesth Pain Med"],"published-print":{"date-parts":[[2024,2]]},"abstract":"<jats:p>In 1981, Devoghel achieved an 85.6% success rate in treating patients with treatment-refractory cluster headaches with alcoholization of the pterygopalatine ganglion (PPG) via the percutaneous suprazygomatic approach. Devoghel\u2019s study led to the theory that interrupting the parasympathetic pathway by blocking its transduction at the PPG could prevent or treat symptoms related to primary headache disorders (PHDs). Furthermore, non-invasive vagus nerve stimulation (nVNS) has proven to treat PHDs and has been approved by national regulatory bodies to treat, among others, cluster headaches and migraines.<\/jats:p><jats:p>In this case series, nine desperate patients who presented with 11 longstanding treatment-refractory primary headache disorders and epidural blood patch\u2013resistant postdural puncture headache (PDPH) received ultrasound-guided percutaneous suprazygomatic pterygopalatine ganglion blocks (PPGB), and seven also received nVNS. The patients were randomly selected and were not part of a research study. They experienced dramatic, immediate, satisfactory, and apparently lasting symptom resolution (at the time of the writing of this report). The report provides the case descriptions, briefly reviews the trigeminovascular and neurogenic inflammatory theories of the pathophysiology, outlines aspects of these PPGB and nVNS interventions, and argues for adopting this treatment regime as a first-line or second-line treatment rather than desperate last-line treatment of PDPH and PHDs.<\/jats:p>","DOI":"10.1136\/rapm-2023-104967","type":"journal-article","created":{"date-parts":[[2023,11,21]],"date-time":"2023-11-21T06:00:12Z","timestamp":1700546412000},"page":"144-150","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":7,"title":["Refractory primary and secondary headache disorders that dramatically responded to combined treatment of ultrasound-guided percutaneous suprazygomatic pterygopalatine ganglion blocks and non-invasive vagus nerve stimulation: a case series"],"prefix":"10.1136","volume":"49","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1221-1214","authenticated-orcid":false,"given":"Andre P","family":"Boezaart","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cameron R","family":"Smith","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yury","family":"Zasimovich","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3517-7450","authenticated-orcid":false,"given":"Rene","family":"Przkora","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9078-1020","authenticated-orcid":false,"given":"Sanjeev","family":"Kumar","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Olga C","family":"Nin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Louis C","family":"Boezaart","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel AJ","family":"Botha","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andr\u00e9","family":"Leonard","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9078-1020","authenticated-orcid":false,"given":"Miguel A","family":"Reina","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Juan A","family":"Pareja","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2023,11,20]]},"reference":[{"key":"2024020504350697000_49.2.144.1","first-page":"101","article-title":"Cluster headache and sphenopalatine block","volume":"32","author":"Devoghel","year":"1981","journal-title":"Acta Anaesthesiol Belg"},{"key":"2024020504350697000_49.2.144.2","first-page":"202","article-title":"Les Traitements des Algies Faciales","volume":"22","author":"Alajuanine","year":"1933","journal-title":"J M\u00e9d Fran\u00e7"},{"key":"2024020504350697000_49.2.144.3","doi-asserted-by":"publisher","DOI":"10.1136\/rapm-2022-104068"},{"key":"2024020504350697000_49.2.144.4","doi-asserted-by":"crossref","first-page":"1366","DOI":"10.1093\/pm\/pnac007","article-title":"Ultrasound-guided suprazygomatic nerve blocks to the pterygopalatine fossa: a safe procedure","volume":"23","author":"Smith","year":"2022","journal-title":"Pain Med"},{"key":"2024020504350697000_49.2.144.5","doi-asserted-by":"publisher","DOI":"10.1177\/0333102417738202"},{"key":"2024020504350697000_49.2.144.6","doi-asserted-by":"crossref","first-page":"651","DOI":"10.1016\/j.ncl.2019.07.008","article-title":"An update: pathophysiology of migraine","volume":"37","author":"Goadsby","year":"2019","journal-title":"Neurol Clin"},{"key":"2024020504350697000_49.2.144.7","doi-asserted-by":"crossref","first-page":"436","DOI":"10.1111\/head.14279","article-title":"Cluster headache pathophysiology: what we have learned from advanced neuroimaging","volume":"62","author":"Silvestro","year":"2022","journal-title":"Headache"},{"key":"2024020504350697000_49.2.144.8","doi-asserted-by":"crossref","first-page":"308","DOI":"10.1038\/s41582-021-00477-w","article-title":"Cluster headache pathophysiology - 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