Status Migrainosus: Sphenopalatine Ganglion Blocks Give Hope

Chronic Migraine can completely destroy the quality of life especially when it is resistant to multiple medications. Self-Administration is the most patient friendly and cost effective approach to delivering Sphenopalatine Ganglion Blocks. It offers almost immediate relief and can save hundreds or thousands of dollars in cost with each and every block once the technique is learned.

This new report published in July 2018 Headache (abstract below) is a welcome addition to the scientific literature on both Status Migrinosus and on Sphenopalatine Ganglion (SPG) Blocks. It covers the Suprazygomatioc injection approach to delivering the blocks.  The Sphenopalatine Ganglion is allso known as the Pterygopalatine Ganglion, Meckel’s Ganglion, the SPG and as Sluders Ganglion after Greenfield Sluder who first described Sphenopalatine Ganglion Blocks in 1908 and later wrote the medical textbook Nasal Neurology.

October 9, 2018 Neurology Advisor reported that “Patients with status migrainosus are at 1.81 times greater risk of attempting suicide than healthy controls, according to a study published in the Journal of Clinical Medicine.  Researchers in this retrospective study analyzed data from the National Health Insurance Research Database of Taiwan for patients diagnosed with regular migraines (n=21,483) or status migrainosus (n=13,605) as well as about 4 times as many matched controls, and then monitored the incidences of suicide attempts.”

Dr Barry Glassman one of the authors who taught me the Suprazygomatic approach to SPG Blocks (SSPGB). I would like to thank him tremendously for passing on that knowledge that I now also teach in my courses both in the US and Internationally.

The study was done on patients resistant to other treatments and showed “Eighty-eight consecutive patients (20 men and 68 women) received a total of 252 suprazygomatic SPG block procedures in the outpatient headache clinic after traditional medications failed to abort their SM. At 30 minutes following the injections, there was a 67.2% (±26.6%) reduction in pain severity”.  This study only looked at immediate relief, 30 minutes but ideally these blocks provide long term relief and decrease in future headache events.

This is an impressive group of patients. I disagree with the statement ” SPG block via transnasal lidocaine is moderately effective in reducing migraine symptoms, but this approach is often poorly tolerated and the results are inconsistent.” The use of self-administration makes it the Most Effective method for those patients who can learn the technique and have good anatomy in their noses.  The book “MIRACLES ON PARK AVENUE” was the story of Dr Milton Reder a NYC ENT whose entire practice was utilizing Sphenopalatine Ganglion Block for treating a wide variety of chronic pain.  Patients traveled from around the world to receive the blocks in his office.  He would repetively give them the blocks once or twice a day foar several days.

In 1930 in the Annals of Internal Medicine (JAMA) Hiram Byrd published a report on Sphenopalatine Phenomena describing results in 2000 patients with 10,000 SPG Blocks not just for headache and migraine but for a wide range of head and neck issues involving a wide range of symptoms relating to the eyes, ears, sinus conditions, and other disorders.

Many physicians are utilizing image guided approach to the SPG Block going through the masseter muscle. I will on occasion utilize this approach if I am also doing masseter or lateral pterygoid trigger point injections and have already anesthesized the skin over the coronoid notch.  The coronoid notch is also where ULF-TENS is applied with a Myomonitor in Neuromuscular Dentistry to relax trigeminal and facial nerve innervated muscles.  A diagnostic neuromuscular orthotic is often the best long term approach to eliminating chronic headaches and migraines.  The Myomonitor also acts as a neuromodulator of the Sphenopalatine Ganglion and has over a fifty year record of safety and efficacy.  Neuromuscular dental treatment can result in massive health care savings over time but more importantly reductions in suffering

There are several methods of injecting the Sphenopalatine Ganglion. I have utilized the intraoral approach the the Greater Palatine Foramen for over 35 years but it has the disadvantage of transitory numbness to the maxillary teeth and to the hard and soft palate. It is extremely safe and reliably allows anesthetic to be delivered to the Sphenopalatine Ganglion. Dentist are the acknowledged experts in this technique which neurologists almost never use. Otolaryngologists (ENTs) are also comforatable with the intra-oral injection but rarely use it.

In addition to injections there are three devices that deliver anesthetic via a nasal catheter to the mucosa over the Pterygopalatine Fossa that holds the Sphenopalatine Ganglion. n The anesthetic can infiltrate thru the mucosa to the ganglion. These devices are the Sphenocath, the Allevio and the TX360. All three of these devices are basically highly specialized “Squirt Guns” designed to deposit the anesthetic solution ideally when the patient is supine during the procedure and for at least 20 minutews after the procedure.

The transnasal cotton-tipped catheter route of administration is probably the single most effective approach when patients can be taught to self administer SPG Blocks. Some patients due to narrow nares are unable to utilize this route.

Self-Administration is the most effective approach to treating chronic pain, whether it is migraine, cluster headache, or any other Trigeminally innervated condition. The beauty of self-administration is that patients in pain no longer have to travel to their physicians offices or the Emergency Room when in severe pain but can immediately begin treatment in the comfort of their homes. They can still head to the ER if the pain is different than anything they have ever experienced previously.

Patient Videos of patients who have had success with SPG Blocks:    https://www.youtube.com/playlist?list=PL5ERlVdJLdtllxAN1QwD7JU7Qo_ISoqvt   These patients were seen by Dr Shapira in his Highland Park office or his Gurnee office.  www.ThinkBetterLife.com ,

An article in 1999  Headache showed excellent results with 4% lidocaine drops vs placebo (abstract below) but other articles have shown that sprays and drops are far less effective that more focused delivery with catheters and/or injections.  Drops are a comfortable method for patients who cannot utilize cotton-tipped catheters for self administration of SPG Blocks.

Another recent article on cost of Cluster Headache Treatment when Sphenopalatine Ganglion Stimulation is added to treatment is reported in Cephalgia , July 2018.  (abstract below)  It concluded that savings in medication were ” Results In the base case analysis, mean annual acute and preventive medication costs decreased from €14,178 to €6924 (-€7254; -51%), and €559 to €328 (-€231; -41%), respectively, leading to total estimated annual drug cost savings of €7484, 97% of which were attributable to acute medications. Conclusions Our analysis suggests that SPG stimulation for the treatment of chronic cluster headache is associated with pronounced reductions in cluster headache medication usage that might lead to sizable annual savings in medication costs.”  In US dollars those net savings are close to $9000.00.

Headache. 2018 Jul 25. doi: 10.1111/head.13390. [Epub ahead of print] The Effect of Regional Anesthetic Sphenopalatine Ganglion Block on Self-Reported Pain in Patients With Status Migrainosus.
Mehta D1, Leary MC1,2, Yacoub HA1,2, El-Hunjul M1, Kincaid H1, Koss V1,2, Wachter K2, Malizia D3, Glassman B4, Castaldo JE5.
Author information
1
Lehigh Valley Health Network, Allentown, PA, USA.
2
Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
3
Allentown Sleep and Pain Center, Allentown, PA, USA.
4
Dr. Barry Glassman Seminars, Allentown, PA, USA.
5
Brownwood Specialty Care Center, The Villages, FL, USA.
Abstract
BACKGROUND:
Status migrainosus (SM) is defined as a debilitating migraine attack lasting more than 72 hours in patients previously known to suffer from migraine headache. Typically, these attacks fail to respond to over the counter and abortive medications. The sphenopalatine ganglion (SPG) plays a critical role in propagating both pain and the autonomic symptoms commonly associated with migraines. SPG block via transnasal lidocaine is moderately effective in reducing migraine symptoms, but this approach is often poorly tolerated and the results are inconsistent. We proposed that an SPG block using a suprazygomatic injection approach would be a safe and effective option to abort or alleviate pain and autonomic symptoms of SM.

METHODS:
Through a retrospective records review, we identified patients with a well-established diagnosis of migraine, based on the International Headache Society criteria. Patients selected for study inclusion were diagnosed with SM, had failed to respond to 2 or more abortive medications, and had received a suprazygomatic SPG block. Patients had also been asked to rate their pain on a 1-10 Likert scale, both before and 30 minutes after the injection.

RESULTS:
Eighty-eight consecutive patients (20 men and 68 women) received a total of 252 suprazygomatic SPG block procedures in the outpatient headache clinic after traditional medications failed to abort their SM. At 30 minutes following the injections, there was a 67.2% (±26.6%) reduction in pain severity with a median reduction of 5 points (IQR= -6 to -3) on the Likert scale (ranging from 1 to 10). Overall, patients experienced a statistically significant reduction in pain severity (P < .0001).

CONCLUSION:
The SPG is known to play an integral role in the pathophysiology of facial pain and the trigeminal autonomic cephalalgias, although its exact role in the generation and maintenance of migraine headache remains unclear. Regional anesthetic suprazygomatic SPG block is potentially effective for immediate relief of SM. We believe the procedure is simple to perform and has minimal risk.

© 2018 American Headache Society.

KEYWORDS:
migraine therapy; migraines; sphenopalatine ganglion; sphenopalatine ganglion block; status migrainosus; suprazygomatic

PMID: 30043973 DOI: 10.1111/head.13390

Cephalalgia. 2018 Jul;38(8):1455-1462. doi: 10.1177/0333102418784689. Epub 2018 Jun 19.

Changes in medication cost observed in chronic cluster headache patients treated with sphenopalatine ganglion (SPG) stimulation: Analysis based on 1-year data from the Pathway R-1 Registry.

Abstract

Background On-demand stimulation of the sphenopalatine ganglion (SPG) by means of an implantable neurostimulation system has been shown to be a safe and effective therapy for treatment-refractory cluster headache patients. Our objective was to estimate changes in cluster headache medication cost observed in SPG-treated chronic patients. Methods Detailed patient-level data of 71 chronic patients treated with the Pulsante® SPG Microstimulator System were available from the Pathway R-1 Registry through 12 months’ follow-up. We used utilization data of preventive and acute medications reported at baseline, 3, 6, 9, and 12 months to estimate annualized drug costs for SPG-treated patients and compared it to baseline. Cost estimates for all drug/dosage combinations were developed based on German medication prices for 2016. Results In the base case analysis, mean annual acute and preventive medication costs decreased from €14,178 to €6924 (-€7254; -51%), and €559 to €328 (-€231; -41%), respectively, leading to total estimated annual drug cost savings of €7484, 97% of which were attributable to acute medications. Conclusions Our analysis suggests that SPG stimulation for the treatment of chronic cluster headache is associated with pronounced reductions in cluster headache medication usage that might lead to sizable annual savings in medication costs.

KEYWORDS:

Chronic cluster headache; Germany; cost-analysis; implantable stimulator; medication costs; sphenopalatine ganglion

PMID:
29921140
DOI:
10.1177/0333102418784689
Headache. 1999 Sep;39(8):543-51.

Intranasal lidocaine for migraine: a randomized trial and open-label follow-up.

Erratum in

  • Headache 1999 Nov-Dec;39(10):764.

Abstract

OBJECTIVE:

To study the efficacy of intranasal lidocaine for the treatment of migraine when administered by subjects in a nonclinic setting.

DESIGN:

A 1-month, randomized, controlled, double-blind trial, followed by a 6-month open-label follow-up.

SETTING:

Ambulatory subjects treating themselves outside of a medical setting.

SUBJECTS:

One hundred thirty-one adult subjects with migraine, diagnosed according to International Headache Society criteria, were enrolled in the study: 113 treated at least one headache in the controlled trial, and 74 treated at least one headache in the open-label phase. All subjects were members of the Kaiser Permanente Southern California Medical Care Program and were recruited at two urban medical centers.

INTERVENTION:

Intranasal lidocaine 4% or saline placebo 0.5 mL was dropped into the nostril on the side of the headache, or bilaterally for bilateral headache, according to study protocol.

MAIN OUTCOME MEASURES:

Trial: percent of headaches relieved to mild or none at 15 minutes and relapse of headache within 24 hours. Open-label: percent of headaches relieved to mild or none at 15 and 30 minutes and relapse within 24 hours.

RESULTS:

In the controlled trial, headache was relieved within 15 minutes in 34 (35.8%) of 95 subjects treated with 4% intranasal lidocaine compared with 8 (7.4%) of 108 subjects receiving placebo (P < .001). Headaches relapsed in 7 (20.6%) of 34 subjects treated with 4% intranasal lidocaine compared to 0 of 8 placebo subjects (P = .312). In the open-label follow-up, headaches were relieved in 129 (41.2%) of 313 episodes within 15 minutes and in 141 (57.6%) of 245 episodes after 30 minutes. Headaches relapsed in 28 (19.9%) of 140. The response did not diminish over time: 32 (62.8%) of 51 first headaches were relieved at 30 minutes and 10 (71.4%) of 14 seventh headaches were relieved. Relapse occurred in 28 (20%) [corrected] of 129 headaches at a mean time (+/- SD) of 7.4 (+/- 6.6) hours.

CONCLUSION:

Intranasal lidocaine 4% provides rapid relief of migraine symptoms. For those subjects who do respond, the effect does not diminish over 6-month follow-up.

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