An article in Pain Medicine News titled “Sphenopalatine Ganglion Block a Viable Therapy for Migraine in Pregnant Patients” looked at safety and efficacy of SPG Blocks to treat migraines during pregnancy according to a team of anesthesiologists at Rutger’s Robert Wood JohnsonUniversity Hospital. SPGB should be considered prior to treatment with systemic medication.
The Sphenopalatine Ganglion Block was first described by Greenfield Sluder in 1908. Sluder’s Neuralgia was named for Dr Sluder but today it is usually coonsidered to be ither cluster headache or other trigeminal autonomic cephalgia combined with symptoms of TMJ disorders. He later went on to write a medical textbook Nasal Neurology and to become head of Otolaryngology at Washington University Medical School in St. Louis. The use of Sphenopalatine Ganglion Block for treating Post-Dural Puncture Headache as a safe alternative to a blood patch has been growing. This is especially important in obstetrics in mothers after delivery who often experience severe headache .
This case report described the patient as a 32-year-old woman at 36 weeks’ gestation. Her medical history included type 1 Arnold Chiari malformation.
“The 32 year old pregnant patient came to the ER with intractable headache that was graded 9.5 of 10 on the pain scale. The neurology team diagnosed the patient with migraines and treated her with IV methylprednisolone and IV morphine. However, the headache persisted at the same level.”
“The anesthesiology team was then consulted, and they evaluated the patient and recommended SPGB,” she said. “The neurology team, however, felt there was minimal data regarding its use in migraines and were not sure that SPGB would be effective.”
“According to Ms. Levin, the patient consented to SPGB treatment, which consisted of intranasal administration of 4% lidocaine solution.”
Dr Ira L Shapira, is a Chicago area Neuromuscular Dentist who teaches courses to dentists and physicians on the use of Sphenopalatine Ganglion Blocks to treat Orofacial pain, TMJ disorders, Trigeminal Neuralgia and Trigeminal innervated Chronic daily headaches, tension headaches, cluster headaches and migraines. Dr Shapira has been teaching patients to self administer SPG Blocks believes that cotton-tipped catheters that offer the advantage of continual capillary delivery of lidocaine may have been a better approach.
This specific case utilized 4% Lidocaine drops which had to repeated numerous times to reach an effective dose to eliminate / control the pain. The use of lidocaine drops requires the patient remains supine and results in lidocaine dripping into pharyngeal areas.. The cotton-tipped nasal catheters allow patients to move around, watch TV or work while the capillary action of the catheters deliver 2% lidocaine to the mucosa over the Sphenopalatine Ganglion. The use of cotton-tipped nasal catheters with continual capillary feed may have been a more effective and give more rapid relief.
There are 3 FDA devices that are basically high-tech squirt guns used to deliver SPG blocks thr the nose. These include the Sphenocath , the Allevio and the TX360. Dr Shapira does use the Sphenocath and the Tx360 on some patients. The Tx360 wass used in studies for the MIRx studies on migraine treatment.
The patient in this report had 4% lidocaine drops several times. to achieve relief. She returned the next day to repeat the procedure. There are multiple methods to deliver SPG Blocks but previous research has shown lower efficacy with lidocaine spray and drops compared to other delivery methods.
This report did have a happy ending with the patient being headache free after the application the following day. Dr Shapira’s patients routinely do their SPG Blocks at home without trips to the ER or their physicians offices.
The article reported “The patient was followed by the hospital pain service for the next six months; the headaches and migraines did not recur, and the baby was born healthy. The team noted that IV methylprednisolone did not relieve the pregnant woman’s symptoms and is a systemic medication that can cause numerous side effects to both the pregnant patient and the baby. Intranasal administration of lidocaine has minimal systemic effects, so it is safer for pregnant women, according to the researchers.”
A 1930 article in the Annals of Internal Medicine (JAMA) by Dr Hiram Byrd et al reported on remarkable success of 10,000 Spenopalatine Ganglion Blocks in 2000 patients with minimal side effects other than slight temporary discomfort. This report included treatment of headaches, migraine, sinus pain, eye pain, back pain and many other disorders.
Dr Shapira has been utilizing Sphenopalatine Ganglion Blocks for over 35 years originally utilizing an intra-oral injection on the hard palate into the Greater Palatine Foramen. This injection can often give immediate relief of severe sinus pain and/or sinus headache. It is also used for maxillary tooth extractions.
The Sphenopalatine Ganglion is also known as the Pterygopalatine Ganglion, Meckels Ganglion and Sluder’s Ganglion. It is located in the Pterygopalatine fossa behind the nose. The fossa also contains the maxillary branch of the Trigeminal Nerve and the maxillary artery. The SPG is the largerst parasympathetic ganglion of the head and it also has sympathetic fibers from the superior cervical chain that pass thru it. The trigeminal nerve is often called the “Dentist’s Nerve” and it is primarily implicated in almost 00% of headaches.
In 986 a patient gave Dr Shapira the book “Miracles on Park Avenue” that detailed the practice of New York City ENT, Dr Milton Reder in New York who utilized Sphenopalatine Ganglion Blocks to treat a wide variety of pain disorders.
The Spehnopalatine Ganglion Block is often referred to as the “Miracle Block” but it became a part of “Forgotten M<edicine” when pharmaceutical companies began to manufacture medications that could be taken as a pill.
Systemic medication may be necessary to treat severe migraines related to pregnancy but lidocaine is far safer than steroids which can have adverse effects on the fetus.
Matthew S. Robbins, MD, the chief of neurology at Jack D. Weiler Hospital of Montefiore Medical Center, in New York City, said he “did not support the opinion that every pregnant woman who presented with chronic migraines should be considered for SPG Block (SPGB) before administering systemic medications; he believed that managing migraines in pregnancy took a much more nuanced approach.” He did however agree “that using non-oral and non-IV medications to treat pregnant women was theoretically ideal to avoid any side effects for the mother or the developing fetus”.
It is also possible to treat migraines in pregnancy with occipital and trigeminal nerve blocks but this will inevitably create higher serum levels of lidocaine than topical nasal application. Lidocaine is safe and a natural anti-inflamatory but keeping exposure low in a pregnant patient increases the margin of safety.
Dr Shapira is currently taking a course in advanced pain management in Boston with Harvard Medical School and the American Academy of Integrative Pain Management.
Dr Zahid H Bajwa director of the Boston Headache Institute gave two excellent lectures on Diagnosis and Treatment of Severe Headache at the meeting. There was a special hands on workshop on injection techniques for severe migraines and chronic headaches that Dr Shapira attended on Tuesday evening. This hands on course also covered therapeutic injections of Botox for severe headache pain. The protocol for using Botox for migraine is different than cosmetic protocols using Botox and require much higher doses.
A A Pract. 2018 Jan 30. doi: 10.1213/XAA.0000000000000722. [Epub ahead of print] Sphenopalatine Ganglion Block Successfully Treats Migraines in a Type 1 Arnold Chiari Malformation Pregnant Patient: A Case Report.
Levin D1, Cohen S, Mellender S, Kiss G.
A 32-year-old woman at 36 weeks gestation with a medical history of corrected Type 1 Arnold Chiari malformation presented with an intractable headache. When methylprednisolone and morphine treatment provided no relief, we performed 2 topical transnasal sphenopalatine ganglion blocks by applying 4% lidocaine drops into each nostril via a cotton-tipped applicator. The patient’s symptoms significantly improved, and she was discharged home the same day. She has been without relapse of headaches during the 6 months of follow-up by our pain service.