Chronic Migraines, Chronic Daily Headaches, and TMJ (TemporoMandibular Joint Dysfunction Syndrome) and Myofascial Pain and Dysfunction: Treatment with SPG Blocks, Neuromuscular Dentistry and Trigger Point Therapy
Learn More about Sphenopalatine Ganglion Blocks and Neuromuscular Dentistry at:
www.thinkbetterlife.com Dr Shapira’s Highland Park Office 847-533-8313
Mary has lived with chronic pain for most of her adult life and can barely remember a time when she was pain free. As a child Mary had frequent sore throats but no signs of infection and her parents were told it was an allergy problem. Wen the pediatrician sent her to an ENT to valuate her tonsils and adenoids they were told that while large the wre not a serious problem and she would grow out of them. As an adolescent her parents were told that she had hormonal headaches and they would get better after puberty. She would never missed school only because of her extreme stamina. She was often taking advil and Tylenol alternatively through the day.
Mary was prescribed birth control pills before her 15th birthday for severe period cramps and to abort her worsening headaches that her pediatrician had called atypical migraines. Mary started orthodontic treatment at 14 but wearing her elastics created pounding headaches and she felt like her head was being smashed in a vice. Her orthodontist complained to her parents that she was an uncooperative patient. After four years of braces the bands were removed and Mary was given retainers.
Mary frequently did not wear her retainers leading to fights with her parents but Mary knew she always woke with more pain if she wore her retainers. Mary was a very motivated student and kept up a Four Point average in spite of ever worsening headaches. She would often go to the school nurse during her free period to lie in a dark room for what her doctors were now diagnosing as ophthalmic headaches.
Excedrin Migraine was now Mary’s drug of choice along with two strong cups of coffee when she first woke. The morning headaches upon awakening were a daily occurrence. She frequently woke up tired and would have hit the snooze alarm but knew the headache would become worse if she skipped her morning coffee. When she woke she often had a dry mouth and a mild sore throat.
Emily, Mary’s sister refused to sleep in the same room with Mary saying she snored too much. Her parents took Mary to an ENT who thought it was allergies and he prescribed antihistamines and nasal sprays which temporarily seemd to help.
At 16 Mary started to apply make up to cover the dark circles under her eyes. Mary’s parents became worried that Mary did not seem to spend much time with her friends any more. Mary was not avoiding her friends she just didn’t have the energy to do her school work and make it through the day anymore. Her friends often thought she was mad a them but actually Mary was no longer able to hide her pain with make-up.
In addition to her headaches /migraines Mary was now having sinus pains, stuffy ears and frequent earaches and her left jaw joint started making clicking and popping noises. Mary would sometimes feel like she could hear crickets chirping or would hear buzzing noises in her ears at night.
In spite of all these problems Mary graduated third in her class and was accepted at several schools and had almost a full year of AP credits. While many of her classmates partied during their first semester Mary was able to keep up her structured study patterns she developed when in high school.
The week before finals was tough on Mary as she had a hard time concentrating on her studying. There seemed to be a perfect storm of headaches, sinus pain, face pain and migraine in a continuous stream. The morning before her last final the pain in her left ear was excruciating. She took two Excedrin Migraine tablets and four advil. After her final she went to the ER and she was told she was in a full blown migraine attack and was given a shot for the pain and one for migraine. The hospital admitted her due to the severity of the pain and Mary’s dismayed parents came to school to take her home.
She had cat scans, MRI’s and even a PET scan but all of the tests appeared normal. Mary started feeling better on the migraine medication and was told she had caffeine withdrawal migraine and maybe food allergies.
A friend of May’s parents recommended she see a chiropractor when Mary complained about Neck Pain in addition to the headaches and sinus pain. This was the first step to a new life for Mary. The Chiropracter she saw, Dr Mark Freund was an Atlas Orthogonal Chiropracter who had also had training in Chirodontics and cranial work as well as being trained in SOT Chiropractic.
Her first appointment was a thorough exam including special x-rays of her neck that allowed Dr Freund to evaluate the relation of her (top two spinal vertebrae) Atlas to her Axis and the occiput of her head.
Her first adjustment to the Atlas was so gentle she was not even sure she felt it but she did hear the click of the adjustment device. Within about 20 minutes the worls seemed “brighter” to Mary and her pain while not eliminated had returned to previos levels they had been in high school.
Mary was referred to Dr Ira Shapira to evaluate her TM Joints (temporomandibular joints) because Dr Freund could not do cranial work due because Mary could open her mouth less than half an inch. Mary’s parents were thrilled to follow Dr Freunds suggestion because it seemed like Mary was getting some relief at last.
The first appointment was to be a consultation but Dr Shapira quickly realized that Mary was having a hard time concentrating and talking due to her jaw pain and headache.
The next few minutes were life changing for Mary. Dr Shapira stopped the consultation and took out a bottle of Ethyl Chloride vapocoolant that he used to spray Mary’s muscles and then he gently stretched her neck muscles one at a time. The vapocoolant evaporates from the skin and feels like bottled cold. Within two minutes almost all of her pain was gone and her parents saw the spark return to Mary’s eyes.
The next issue was the jaw not opening, using the same spray over her jaw muscles Dr Shapira tried to stretch them but this caused immediate sharp pain. At this point careful measurements were taken of how Mary’s jaw moved side to side, forward and what happened when she tried to open . Dr Shapira explained that he thought that there was a Close-Lock internal derangement of the disk in Mary’s left TMJoint.
Up to this point Dr Shapira, a dentist had never even looked at Mary’s teeth. He asked if he could try to redure the dislocated joint. He explained how the longer the jaw is locked the harder it is to unlock and that the procedure could be uncomfortable. Mary and her parents said to go ahead. The next couple of minutes went by very quickly as the doctor again sprayed the cold spray over her jaw muscles, her scalp and over both jaw joints, he the had Mary open slightly and he place the mouth mirror slightly over her tongue. The without warning he slid the mirror all the way to the back of Mary’s throat as she instantly tried to grab his hand away she had a huge gag response and her mouth opened all the way with a very loud pop.
Dr Shapira quickly slid a cotton roll between her front teeth and let Mary close her mouth until the front teeth hit the cotton roll. He then had her open and close her mouth several times but did not let her close all the way. Immediately Mary said she could not remember the last time she could open her mouth so wide.
Mary was taught how to unlock her own jaw in case it ever locked again. Mary’s mouth was kept propped open with tongue blades for about 10 minutes and then she was allowed to slowly close back on her own teeth however just as she started to bring her back teeth together she locked again and her eyes immediately started to tear. It was easier to unlock the second time but this led to a long discussion on how Neuromuscular Dentistry utilizes diagnostic orthotics to stabilize and treat TMJ problems (internal derangements) and Myofascial Pain and Dysfunction the muscle trigger points in the nack and jaw muscles that caused her headaches.
Mary was given a small tubular device called an Aqualizer that was placed in her mouth so she could close her mouth almost completely and Dr Shapira made sure that it prevented her jaw from locking. Neuromuscular dentistry and treatment was described in detail to Mary and she was told that if the diagnostic phase of treatment was successful she might need additional treatment in the future.
Mary’s parents elected to have Mary start treatment that day because she was scheduled to return to school in just over two weeks. A Myomonitor was placed on Mary, it is a special type of ultra low frequency TENS that is used to relax the jaw muscles gradually.
A panoramic x-ray and impressions were taken in order to make an orthotic. While Mary was sitting with her parents she suddenly began to sob, almost hysterically. Her parents were very concerned until Mary said “I cannot remember the last time I did not have severe pain, I can’t believe it is possible to feel this good. Now it was Mary’s mother who started to cry.
The next steps were equally amazing as Dr Shapira asked Mary if there was any pain left at all and at first Mary didn’t want to say anything because it was the best she could remember feeling in so many years but she finally pointed to her shoulders and said they still felt “sore and tight”. Dr Shapira again utilized the cold spray and explained the Spray and Stretch technique he was using and he relieved the pain in her shoulders, neck, and mid back as well between her shoulder blades. By this time Mary was laughing ans smiling and her parents could see their daughter how she used to be.
Dr Shapira told them about Dr Janet Travell who invented this technique and actually used it on President Kennedy to relieve his severe pain while she was his personal physician at the White House. Jackie Kennedy built the Planted the Rose Garden in her honour because she loved roses.
There was one pain in her eyebrow that could not be eliminated and a procedure called a SphenoPalatineGanglion Block or SPG Block was explained. It utilizes safe dental anaesthetic that is applied through the nose by hollow cotton tipped applicators. The block quickly relieved the eyebrow pain but something else happened as well. Mary suddenly looks at her mom and said “the cramps are gone”. Mary had never mentioned these cramps during the initial part of the visit but these had been a problem Mary had ever since puberty.
This led to a whole new discussion about the autonomic nervous system and how the the autonomic branches of the Trigeminal Nerve and other nerves ipass thru this area. Dr Shapira recommended that they find a copy of the book, MIRACLES ON PARK AVENUE, about a doctor whose entire practice was treating all types of chronic pain utilizing sphenopalatine ganglion blocks. There are several pubmed abstracts about SPG blocks at the end of this article.
Dr Shapira started utilizing the SPG Block after one of his patients brought the book in shortly after it was published about 25 years ago and wanted him to learn the technique.
The real beauty of this technique is that it is extremely safe and easy.
The rest of the day flew by and Mary received her Diagnostic Neuromuscular Orthotic that fit almost invisibly on her lower teet, prevented the locking and caused no problems with talking. Mary was told to keep the Aqualizer she had worn for the last several hours as a back up appliance. (She would need it a few weeks later when she dropped and broke her appliance a few weeks later.
Normally patients with severe close locks are seen back the next day but because of a long weekend Mary was not seen again for four days. The Mary who came back was not the same Mary who had been in four days ago, in fact she was a Mary her parents had never experienced. She was full of energy, laughing and smiling. The dark ares under her eyes were gone without make-up.
In spite of how great she looked and felt Mary admitted that there were still symptoms but she was afraid to have her appliance adjusted because she never wanted to go back to the previous pain.
A long discussion on how there was a road to be travelled back to health and that there might be some bumps in the road. Mary felt “cured” but it was explained the only real cure would be a do-over on the last 10 years of her life. She was forever changed from her experiences and had built up a very high threshold for pain.
Even though Mary felt great utilizing the spray and stretch technique made her feel even better. Mary was surprised because she did not think it was possible. The concept of pain threshold was explained to Mary and her parents and how she had learned to use an icredible amount of energy covering up her pain. As the pain improves her threshold lowers, this is the body healing. There is an enormous difference between optimal health and merely being out of pain.
Mary made two more trips to have her orthotic adjusted and four trips to Dr Freund before the start of her next semester and was feeling great. Over semester break she reconnected with her friends who could believe the changes.
Six weeks later Dr Shapira received a panicked call from Mary’s mother. The orthotic had broken and Mary had locked and the pain was worse than ever.
Dr Shapira immediately called Mary and she still had her Aqualizer from the first appointment. He talked her through gagging herself to reduce the close-lock dislocation and Mary utilized the Srpay and Stretch techniques she had learned and could eliminate most of the pain. Later, Mary would comment that on this day she knew she would be alright, because with Dr Shapira’s help she was now in control, she had “fixed the problem” and she didn’t feel helpless anymore. This gave her a new confidence and strength that she had never known possible.
Mary decided she needed to come back to town to have her orthotic fixed and see Dr Feund. She spent most of the next day travelling up and back between their offices and on Thursday Dr Freund came into dr Shapira’s office and did cranial adjustments alternating with Dr Shapira’s adjustments to the diagnostic orthotic.
Mary also mentioned her snoring was getting worse with allergy season and it was arranged to have a sleep study prior to her return from school. She was also taught how to self administer SPG Blocks and bought 6 more Aqualizers to take to school as emergeny back ups.
It turned out that Mary had mild sleep apnea and UARS or upper airway resistance syndrome. Mary’s parents were also tested for sleep apnea after realizing they had many symptoms of sleep apnea as well, her mother was diagnosed with moderate sleep apnea and her father was diagnosed with severe sleep apnea.
Mary’s parents were both made oral appliances to treat their snoring and sleep apnea and felt more energetic and rested.
Mary was not seen until the end of the school year and because she was out of pain for months a second phase of treatment was discussed. A long term orthotic could be made but Mary did not want to have to wear an appliance forever. In fact her biggest complaint now was not pain but just being tired of waring an appliance.
Orthodontics was discussed but Mary was adamant that her previous orthodontic treatment was torture and she refused to even consider it. Mary wanted to do ceramic onlays as a long term solution but Dr Shapira convinced her to try the DNA Appliance and Epigenetic Orthodontics first because it could also cure her snoring and sleep apnea. Mary agreed to try it for 6 months. After 6 months the snoring and apnea was relieved and even the allergies were better due to better breathing and a larger airway but Mary did not want to wait on getting rid of her appiances and so Dr Shapira placed the veneer onlays. 6 veneer onlays were placed on her lower back teeth to replace the appliance and stabilize the bite. No anaesthetic or tooth preparation was required.
Mary continued to see Dr Shapira and Dr Freund during school breaks and will have yearly evaluations on an ongoing basis.
Mary’s story is actually a composite story of several patients treated by Dr Shapira and Dr Freund. It is not uncommon for multiple diagnosis over time with TMJ Disorders (TMD) and that is why they are called “THE GREAT IMPOSTER”
Frequently patients are treated for depression. Depression is a normal response to severe chronic pain. Patients who are in constant pain often recover from their depression without medication once their pain is relieved or eliminated.
There are numerous methods of treating TMJ disorders and chronic pain. Dr Shapira has over 35 years experience in helping patients like Mary.
Dr Shapira recently lectured in Argentina on the common development pathways of sleep apnea and TMJ disorders. The National Heart Lung and Blood Institute published a report “CARDIOVASCULAR AND SLEEP-RELATED CONSEQUENCES OF TEMPOROMANDIBULAR DISORDERS” than can be found at http://www.nhlbi.nih.gov/files/docs/workshops/tmj_wksp.pdf
Dr Shapira’s contact number is 847-533-8313. Please leave a message and you will be contacted or you can contact us at www.THINKBETTERLIFE.com.
Learn more about Neuromuscular Dentistry and Headache Elimination at:
Learn more about the dangers and treatment of Sleep Apnea and Snoring at
Below are several PubMed Abstracts concerning Sphenopalatine Ganglion Blocks. While they can give miraculous results SPG Blocks should be considered one aspect of a comprehensive treatment plan.
Patients experiencing new headache pain of a severe nature should always have a medical evaluation to rule out serious medical disorders. Chronic pain is the focus of this article.
##### The first two articles below describe a new device, the TRX360 for delivering Sphenopalatine Ganglion Blocks. Dr Shapira usually prefers the hollow swab delivery because it is easy for patients to self administer and is extremely inexpensive for patients.
The balance all discuss utilization of SPG Blocks for treating a vaiety of conditions including Trigeminal Neuralgia, Migraine, chronic daily headache, otalgia, sinus pain, facial pain, atypical facial pain, Sluders Neuralgia, Orofacial Pain, paroxysmal hemicrania, complex regional pain syndrome, CRPS, Cluster Headaches, Tension Headaches, rhinologic headaches and of course TMJ Disorders, THE GREAT IMPOSTER
Headache. 2014 Oct 23. doi: 10.1111/head.12458. [Epub ahead of print]
A Double-Blind, Placebo-Controlled Study of Repetitive Transnasal Sphenopalatine Ganglion Blockade With Tx360® as Acute Treatment for Chronic Migraine.
Cady R1, Saper J, Dexter K, Manley HR.
To determine if repetitive sphenopalatine ganglion (SPG) blocks with 0.5% bupivacaine delivered through the Tx360® are superior in reducing pain associated with chronic migraine (CM) compared with saline.
The SPG is a small concentrated structure of neuronal tissue that resides within the pterygopalatine fossa (PPF) in close proximity to the sphenopalatine foramen and is innervated by the maxillary division of the trigeminal nerve. From an anatomical and physiological perspective, SPG blockade may be an effective acute and preventative treatment for CM.
This was a double-blind, parallel-arm, placebo-controlled, randomized pilot study using a novel intervention for acute treatment in CM. Up to 41 subjects could be enrolled at 2 headache specialty clinics in the US. Eligible subjects were between 18 and 80 years of age and had a history of CM defined by the second edition of the International Classification of Headache Disorders appendix definition. They were allowed a stable dose of migraine preventive medications that was maintained throughout the study. Following a 28-day baseline period, subjects were randomized by computer-generated lists of 2:1 to receive 0.5% bupivacaine or saline, respectively. The primary end-point was to compare numeric rating scale scores at pretreatment baseline vs 15 minutes, 30 minutes, and 24 hours postprocedure for all 12 treatments. SPG blockade was accomplished with the Tx360® , which allows a small flexible soft plastic tube that is advanced below the middle turbinate just past the pterygopalatine fossa into the intranasal space. A 0.3 cc of anesthetic or saline was injected into the mucosa covering the SPG. The procedure is performed similarly in each nostril. The active phase of the study consisted of a series of 12 SPG blocks with 0.3 cc of 0.5% bupivacaine or saline provided 2 times per week for 6 weeks. Subjects were re-evaluated at 1 and 6 months postfinal procedure.
The final dataset included 38 subjects, 26 in the bupivacaine group and 12 in the saline group. A repeated measures analysis of variance showed that subjects receiving treatment with bupivacaine experienced a significant reduction in the numeric rating scale scores compared with those receiving saline at baseline (M = 3.78 vs M = 3.18, P = .10), 15 minutes (M = 3.51 vs M = 2.53, P < .001), 30 minutes (M = 3.45 vs M = 2.41, P < .001), and 24 hours after treatment (M = 4.20 vs M = 2.85, P < .001), respectively. Headache Impact Test-6 scores were statistically significantly decreased in subjects receiving treatments with bupivacaine from before treatment to the final treatment (Mdiff = -4.52, P = .005), whereas no significant change was seen in the saline group (Mdiff = -1.50, P = .13). CONCLUSION: SPG blockade with bupivacaine delivered repetitively for 6 weeks with the Tx360® device demonstrates promise as an acute treatment of headache in some subjects with CM. Statistically significant headache relief is noted at 15 and 30 minutes and sustained at 24 hours for SPG blockade with bupivacaine vs saline. The Tx360® device was simple to use and not associated with any significant or lasting adverse events. Further research on sphenopalatine ganglion blockade is warranted. © 2014 American Headache Society. KEYWORDS: Tx360®; acute treatment; chronic migraine; preventive treatment; sphenopalatine ganglion block Pain Physician. 2013 Nov-Dec;16(6):E769-78. A novel revision to the classical transnasal topical sphenopalatine ganglion block for the treatment of headache and facial pain. Candido KD1, Massey ST, Sauer R, Darabad RR, Knezevic NN. Author information Abstract BACKGROUND: The sphenopalatine ganglion (SPG) is located with some degree of variability near the tail or posterior aspect of the middle nasal turbinate. The SPG has been implicated as a strategic target in the treatment of various headache and facial pain conditions, some of which are featured in this manuscript. Interventions for blocking the SPG range from minimally to highly invasive procedures often associated with great cost and unfavorable risk profiles. OBJECTIVE: The purpose of this pilot study was to present a novel, FDA-cleared medication delivery device, the Tx360® nasal applicator, incorporating a transnasal needleless topical approach for SPG blocks. This study features the technical aspects of this new device and presents some limited clinical experience observed in a small series of head and face pain cases. STUDY DESIGN: Case series. SETTINGS: Pain management center, part of teaching-community hospital, major metropolitan city, United States. METHODS: After Institutional Review Board (IRB) approval, the technical aspects of this technique were examined on 3 patients presenting with various head and face pain conditions including trigeminal neuralgia (TN), chronic migraine headache (CM), and post-herpetic neuralgia (PHN). The subsequent response to treatment and quality of life was quantified using the following tools: the 11-point Numeric Rating Scale (NRS), Modified Brief Pain Inventory – short form (MBPI-sf), Patient Global Impression of Change (PGIC), and patient satisfaction surveys. The Tx360® nasal applicator was used to deliver 0.5 mL of ropivacaine 0.5% and 2 mg of dexamethasone for SPG block. Post-procedural assessments were repeated at 15 and 30 minutes, and on days one, 7, 14, and 21 with a final assessment at 28 days post-treatment. All patients were followed for one year. Individual patients received up to 10 SPG blocks, as clinically indicated, after the initial 28 days. RESULTS: Three women, ages 43, 18, and 15, presented with a variety of headache and face pain disorders including TN, CM, and PHN. All patients reported significant pain relief within the first 15 minutes post-treatment. A high degree of pain relief was sustained throughout the 28 day follow-up period for 2 of the 3 study participants. All 3 patients reported a high degree of satisfaction with this procedure. One patient developed minimal bleeding from the nose immediately post-treatment which resolved spontaneously in less than 5 minutes. Longer term follow-up (up to one year) demonstrated that additional SPG blocks over time provided a higher degree and longer lasting pain relief. LIMITATIONS: Controlled double blind studies with a higher number of patients are needed to prove efficacy of this minimally invasive technique for SPG block. CONCLUSION: SPG block with the Tx360® is a rapid, safe, easy, and reliable technique to accurately deliver topical transnasal analgesics to the area of mucosa associated with the SPG. This intervention can be delivered in as little as 10 seconds with the novice provider developing proficiency very quickly. Further investigation is certainly warranted related to technique efficacy, especially studies comparing efficacy of Tx360 and standard cotton swab techniques. PMID: 24284858 [PubMed – indexed for MEDLINE] Free full text J Pain Palliat Care Pharmacother. 2006;20(3):57-9. Intranasal sphenopalatine ganglion block: minimally invasive pharmacotherapy for refractory facial and headache pain. Obah C1, Fine PG. Author information Abstract Facial pain and headache of various etiologies are oftentimes unresponsive to conventional therapies. Transnasal sphenopalatine gangion block provides a safe, low-cost, therapy that, if effective, oftentimes can be self-administered for pain relief. Otolaryngol Pol. 2007;61(3):319-21. [Atypical facial pains–sluder’s neuralgia–local treatment of the sphenopalatine ganglion with phenol–case report]. [Article in Polish] Olszewska-Ziaber A1, Ziaber J, Rysz J. Author information Abstract AIM: Chronic reccuring head and facial pain can be very difficult for successful treatment. Such a pain can be in some rare cases Sluder’s sphenopalatine ganglion neuralgia. The aim of the study was to obtain the pain relief by local treatment in patients with Sluder’s sphenopalatine ganglion neuralgia. METHODS: We described three cases of Sluder’s neuralgia among all the seventeen patients with reccuring head and face pain that were seen in our department. In all these cases 4% Xylocaine was applied intranasally, into the region of shenopalatine ganglion, behind the posterior tip of the middle turbinate four times for ten minutes. According to Kern, the diagnosis of Sluder’s neuralgia was confirmed only in cases where local anesthetic block of the sphenopaltine ganglion was successful. It means the patients were pain-free for at least an hour after application of Xylocaine, so they were qualified for phenolization and 88% phenol was applied on the cotton carriers (number of the applications depended on the patient). RESULTS: The total relief of pain of different duration was obtained in all the presented cases. CONCLUSION: The relief of pain obtained by intranasal phenolization of sphenopalatine ganglion in three patients shows it could be the effective treatment of Sluder’s neuralgia. The patients were totally free from the pain and accompanying symptoms like nasal obstruction, rhinorrhea, epiphora or conjunctivitis. The relief period was different but the patients were satisfied with the effectiveness and simplicity of the treatment. They did not need to take the additional medications for months and were able to continue work. PMID: 17847789 [PubMed – indexed for MEDLINE] Cephalalgia. 2010 Mar;30(3):360-4. doi: 10.1111/j.1468-2982.2009.01919.x. Sluder’s neuralgia: a trigeminal autonomic cephalalgia? Oomen KP1, van Wijck AJ, Hordijk GJ, de Ru JA. Author information Abstract The objective was to formulate distinctive criteria to substantiate our opinion that Sluder’s neuralgia and cluster headache are two different clinical entities. A systematic review was carried out of all available, original literature on Sluder’s neuralgia. Pain characteristics, periodicity and associated signs and symptoms were studied and listed according to frequency of appearance. Eleven articles on Sluder’s neuralgia were evaluated. Several differences between Sluder’s neuralgia and cluster headache became evident. Based on described symptoms, new criteria for Sluder’s neuralgia could be formulated. Sluder’s neuralgia and cluster headache could possibly be regarded as two different headache syndromes, and Sluder’s neuralgia could be a trigeminal autonomic cephalalgia. PMID: 19614698 [PubMed – indexed for MEDLINE] Cranio. 1995 Jul;13(3):177-81. Sphenopalatine ganglion block: a safe and easy method for the management of orofacial pain. Peterson JN1, Schames J, Schames M, King E. Author information Abstract The sphenopalatine ganglion (SPG) block is a safe, easy method for the control of acute or chronic pain in any pain management office. It takes only a few moments to implement, and the patient can be safely taught to effectively perform this pain control procedure at home with good expectations and results. Indications for the SPG blocks include pain of musculoskeletal origin, vascular origin and neurogenic origin. It has been used effectively in the management of temporomandibular joint (TMJ) pain, cluster headaches, tic douloureux, dysmenorrhea, trigeminal neuralgia, bronchospasm and chronic hiccup. PMID: 8949858 [PubMed – indexed for MEDLINE] Acta Otorhinolaryngol Ital. 2012 Apr;32(2):77-86. Headaches of otolaryngological interest: current status while awaiting revision of classification. Practical considerations and expectations. Farri A1, Enrico A, Farri F. Author information Abstract In 1988, diagnostic criteria for headaches were drawn up by the International Headache Society (IHS) and is divided into headaches, cranial neuralgias and facial pain. The 2(nd) edition of the International Classification of Headache Disorders (ICHD) was produced in 2004, and still provides a dynamic and useful instrument for clinical practice. We have examined the current IHC, which comprises 14 groups. The first four cover primary headaches, with “benign paroxysmal vertigo of childhood” being the forms of migraine of interest to otolaryngologists; groups 5 to 12 classify “secondary headaches”; group 11 is formed of “headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures”; group 13, consisting of “cranial neuralgias and central causes of facial pain” is also of relevance to otolaryngology. Neither the current classification system nor the original one has a satisfactory collocation for migraineassociated vertigo. Another critical point of the classification concerns cranio-facial pain syndromes such as Sluder’s neuralgia, previously included in the 1988 classification among cluster headaches, and now included in the section on “cranial neuralgias and central causes of facial pain”, even though Sluder’s neuralgia has not been adequately validated. As we have highlighted in our studies, there are considerable similarities between Sluder’s syndrome and cluster headaches. The main features distinguishing the two are the trend to cluster over time, found only in cluster headaches, and the distribution of pain, with greater nasal manifestations in the case of Sluder’s syndrome. We believe that it is better and clearer, particularly on the basis of our clinical experience and published studies, to include this nosological entity, which is clearly distinct from an otolaryngological point of view, as a variant of cluster headache. We agree with experts in the field of headaches, such as Olesen and Nappi who contributed to previous classifications, on the need for a revised classification, particularly with regards to secondary headaches. According to the current Committee on headaches, the updated version of the classification, presently under study, is due to be published soon; it is our hope that this revised version will take into account some of the above considerations. KEYWORDS: Charlin’s neuralgia; Cranial neuralgias ; ENT; Facial pain; International Headache Classification; Migraine; Sluder’s neuralgia; Vestibular migraine; Headache Pain Pract. 2012 Jun;12(5):399-412. doi: 10.1111/j.1533-2500.2011.00507.x. Epub 2011 Sep 29. The pterygopalatine ganglion and its role in various pain syndromes: from anatomy to clinical practice. Piagkou M1, Demesticha T, Troupis T, Vlasis K, Skandalakis P, Makri A, Mazarakis A, Lappas D, Piagkos G, Johnson EO. Author information Erratum in Pain Pract. 2012 Nov;12(8):673. Abstract The postsynaptic fibers of the pterygopalatine or sphenopalatine ganglion (PPG or SPG) supply the lacrimal and nasal glands. The PPG appears to play an important role in various pain syndromes including headaches, trigeminal and sphenopalatine neuralgia, atypical facial pain, muscle pain, vasomotor rhinitis, eye disorders, and herpes infection. Clinical trials have shown that these pain disorders can be managed effectively with sphenopalatine ganglion blockade (SPGB). In addition, regional anesthesia of the distribution area of the SPG sensory fibers for nasal and dental surgery can be provided by SPGB via a transnasal, transoral, or lateral infratemporal approach. To arouse the interest of the modern-day clinicians in the use of the SPGB, the advantages, disadvantages, and modifications of the available methods for blockade are discussed.▪ © 2011 The Authors. Pain Practice © 2011 World Institute of Pain. Cephalalgia. 2010 Mar;30(3):365-7. doi: 10.1111/j.1468-2982.2009.01882.x. Epub 2010 Feb 1. Does sphenopalatine endoscopic ganglion block have an effect in , A case report. Morelli N1, Mancuso M, Felisati G, Lozza P, Maccari A, Cafforio G, Gori S, Murri L, Guidetti D. Author information Abstract The authors report the case of a 69-year-old woman suffering from paroxysmal hemicrania (PH), intolerant to indomethacin and resistant to multiple therapies, in which sphenopalatine endoscopic ganglion block (SPG) dramatically modified the clinical outcome. SPG blockade could be considered a reasonable alternative in drug-resistant PH cases where indomethacin is contraindicated. PMID: 19438918 [PubMed – indexed for MEDLINE] Arch Phys Med Rehabil. 2005 Feb;86(2):335-7. Complex regional pain syndrome involving the lower extremity: a report of 2 cases of sphenopalatine block as a treatment option. Quevedo JP1, Purgavie K, Platt H, Strax TE. Author information Abstract We report 2 cases of complex regional pain syndrome (CRPS) involving the lower extremity; in both, a sphenopalatine ganglion (SPG) block was performed as part of a pain management program. In the first case, a woman in her late twenties presented with CRPS in the left lower extremity that was inadequately controlled with typical oral medications. Sympathetic block of the extremity did not provide significant pain relief. However, a noninvasive sphenopalatine block with 4% tetracaine resulted in a 50% reduction in pain level. The patient was shown how to self-administer the sphenopalatine block and was provided with exercises and therapy to help improve her functional status. The second case involved a woman in her mid forties with CRPS in the right lower extremity that was partially controlled with oral medications. The patient experienced a 50% reduction in pain level when SPG block with 4% tetracaine was given. Further study is needed to determine the effects of SPG blocks on symptoms related to chronic regional pain syndrome. PMID: 15706564 [PubMed – indexed for MEDLINE] Results: 1 to 20 of 379 Select item 24995309 1. Differential diagnostics of pain in the course of trigeminal neuralgia and temporomandibular joint dysfunction. Pihut M, Szuta M, Ferendiuk E, Zeńczak-Więckiewicz D. Biomed Res Int. 2014;2014:563786. doi: 10.1155/2014/563786. Epub 2014 Jun 4. PMID: 24995309 [PubMed – in process] Free PMC Article Related citations Select item 24680494 2. Evaluation and management of “sinus headache” in the otolaryngology practice. Patel ZM, Setzen M, Poetker DM, DelGaudio JM. Otolaryngol Clin North Am. 2014 Apr;47(2):269-87. doi: 10.1016/j.otc.2013.10.008. PMID: 24680494 [PubMed – in process] Related citations Select item 24661509 3. Facial nerve compression by the posterior inferior cerebellar artery causing facial pain and swelling: a case report. Batten RL, Ng WF. J Med Case Rep. 2014 Mar 25;8:105. doi: 10.1186/1752-1947-8-105. PMID: 24661509 [PubMed – in process] Free PMC Article Related citations Select item 24466618 4. Current thinking in the examination and management of the TMJ. Kassam K. Prim Dent J. 2013 Oct;2(4):19-20. No abstract available. PMID: 24466618 [PubMed – indexed for MEDLINE] Related citations Select item 24261452 5. Orofacial pain: a guide for the headache physician. Shephard MK, Macgregor EA, Zakrzewska JM. Headache. 2014 Jan;54(1):22-39. doi: 10.1111/head.12272. Epub 2013 Nov 21. Review. PMID: 24261452 [PubMed – indexed for MEDLINE] Related citations Select item 24217113 6. Use of an artificial neural network for diagnosis of facial pain syndromes: an update. McCartney S, Weltin M, Burchiel KJ. Stereotact Funct Neurosurg. 2014;92(1):44-52. doi: 10.1159/000353188. Epub 2013 Nov 8. PMID: 24217113 [PubMed – indexed for MEDLINE] Related citations Select item 24020967 7. Auriculotemporal neuralgia secondary to TMJ synovial cyst: a rare presentation of a rare entity. Ansari H, Robertson CE, Lane JI, Viozzi CF, Garza I. Headache. 2013 Nov-Dec;53(10):1662-5. doi: 10.1111/head.12196. Epub 2013 Sep 10. PMID: 24020967 [PubMed – indexed for MEDLINE] Related citations Select item 23971349 8. Oral medicine. 9: Orofacial pain. Felix DH, Luker J, Scully C. Dent Update. 2013 Jul-Aug;40(6):493-501. No abstract available. PMID: 23971349 [PubMed – indexed for MEDLINE] Related citations Select item 23809301 9. Differential diagnosis of orofacial pain and temporomandibular disorder. Kumar A, Brennan MT. Dent Clin North Am. 2013 Jul;57(3):419-28. doi: 10.1016/j.cden.2013.04.003. Epub 2013 May 23. Review. PMID: 23809301 [PubMed – indexed for MEDLINE] Related citations Select item 23809299 10. Clinical assessment of patients with orofacial pain and temporomandibular disorders. Stern I, Greenberg MS. Dent Clin North Am. 2013 Jul;57(3):393-404. doi: 10.1016/j.cden.2013.04.002. Review. PMID: 23809299 [PubMed – indexed for MEDLINE] Related citations Select item 23794651 11. Differential diagnosis of facial pain and guidelines for management. Zakrzewska JM. Br J Anaesth. 2013 Jul;111(1):95-104. doi: 10.1093/bja/aet125. Review. PMID: 23794651 [PubMed – indexed for MEDLINE] Free Article Related citations Select item 23715202 12. Atypical odontalgia: an up-to-date view. Tarce M, Barbieri C, Sardella A. Minerva Stomatol. 2013 May;62(5):163-81. Review. English, Italian. PMID: 23715202 [PubMed – indexed for MEDLINE] Related citations Select item 23614082 13. Secondary trigeminal neuralgia caused by pharyngeal squamous cell carcinoma – a case report -. Kim MS, Ryu YJ, Park SY, Kim HY, An S, Kim SW. Korean J Pain. 2013 Apr;26(2):177-80. doi: 10.3344/kjp.2013.26.2.177. Epub 2013 Apr 3. PMID: 23614082 [PubMed] Free PMC Article Related citations Select item 23520364 14. Interaction of IL-1β and P2X(3) receptor in pathologic masseter muscle pain. Noma N, Shinoda M, Honda K, Kiyomoto M, Dezawa K, Nakaya Y, Komiyama O, Imamura Y, Iwata K. J Dent Res. 2013 May;92(5):456-60. doi: 10.1177/0022034513483770. Epub 2013 Mar 21. PMID: 23520364 [PubMed – indexed for MEDLINE] Related citations Select item 23476731 15. An evidence-based review of botulinum toxin (Botox) applications in non-cosmetic head and neck conditions. Persaud R, Garas G, Silva S, Stamatoglou C, Chatrath P, Patel K. JRSM Short Rep. 2013 Feb;4(2):10. doi: 10.1177/2042533312472115. Epub 2013 Feb 12. PMID: 23476731 [PubMed] Free PMC Article Related citations Select item 23339268 16. Temporomandibular disorders and occlusion. Badel T, Marotti M, Pavicin IS, Basić-Kes V. Acta Clin Croat. 2012 Sep;51(3):419-24. Review. PMID: 23339268 [PubMed – indexed for MEDLINE] Related citations Select item 23045786 17. Sporting injuries to the temporomandibular joint. Canavan D. J Ir Dent Assoc. 2012 Aug-Sep;58(4):202-4. No abstract available. PMID: 23045786 [PubMed – indexed for MEDLINE] Related citations Select item 23031688 18. Trigeminal neuralgia post-styloidectomy in Eagle syndrome: a case report. Blackett JW, Ferraro DJ, Stephens JJ, Dowling JL, Jaboin JJ. J Med Case Rep. 2012 Oct 2;6:333. doi: 10.1186/1752-1947-6-333. PMID: 23031688 [PubMed] Free PMC Article Related citations Select item 22970601 19. Differential diagnosis of toothache pain. Part 2, nonodontogenic etiologies. Germain L. Dent Today. 2012 Aug;31(8):84, 86, 88-9. PMID: 22970601 [PubMed – indexed for MEDLINE] Related citations Select item 22936556 20. Clinical anatomy of the auriculotemporal nerve in the area of the infratemporal fossa. Komarnitki I, Andrzejczak-Sobocińska A, Tomczyk J, Deszczyńska K, Ciszek B. Folia Morphol (Warsz). 2012 Aug;71(3):187-93. PMID: 22936556 [PubMed – indexed for MEDLINE] Int J Obstet Anesth. 2014 Aug;23(3):292-3. doi: 10.1016/j.ijoa.2014.04.010. Epub 2014 May 10. Transnasal topical sphenopalatine ganglion block to treat tension headache in a pregnant patient. Grant GJ1, Schechter D2, Redai I2, Lax J2. Author information Rinsho Shinkeigaku. 2013;53(11):1131-3. [New treatments for cluster headache]. [Article in Japanese] Shimizu T. Author information Abstract Subcutaneous injection and nasal spray of sumatriptan are known to be useful for the treatment of acute phase of cluster headache. Although nasal spry of zolmitriptan is not available in Japan, it is also reported to be effective for the acute phase of cluster headache. In addition, high flow oxygen is also reported to abort the attack of cluster headache. For preventive treatment of cluster headache, calcium channel blocker (verapamil) and steroids are recommended. In addition to these medications, some of refractory chronic cluster headache patients are reported to be respond to the occipital nerve block, deep brain stimulation, vagus nerve stimulation and occipital nerve stimulation. Furthermore, recent report revealed that stimulation of the sphenopalatine ganglion is effective for acute pain relief and attack prevention. This review will introduce the recent treatment for cluster headache including these nerve stimulations. Headache. 2013 Jul-Aug;53(7):1183-90. doi: 10.1111/head.12148. Epub 2013 Jun 28. Cluster headache: potential options for medically refractory patients (when all else fails). Tepper SJ1, Stillman MJ. Author information Abstract The most evidence exists for mixed anesthetic/steroid occipital nerve blocks (which are also useful in non-refractory patients), deep brain stimulation, sphenopalatine ganglion (SPG) blocks, SPG radiofrequency ablation, and SPG stimulation with the Autonomic Technologies, Inc (ATI) SPG Neurostimulator, the latter approved in the European Union and reimbursed in several countries. © 2013 American Headache Society. KEYWORDS: LSD; cluster headache; neuromodulation; occipital nerve block; sphenopalatine ganglion stimulation; vagal nerve stimulation PMID: 23808603 [PubMed – indexed for MEDLINE] Int Forum Allergy Rhinol. 2012 Jul-Aug;2(4):325-30. doi: 10.1002/alr.21035. Epub 2012 Apr 5. Endoscopic neural blockade for rhinogenic headache and facial pain: 2011 update. Rodman R1, Dutton J. Author information Abstract BACKGROUND: Over 45 million Americans suffer from recurrent headaches, and an estimated $11.9 million was spent on doctor’s visits for rhinogenic pain last year. Sphenopalatine blocks have been described for various facial pain syndromes, but their use and the type of blockade agents remain controversial. The objective of this study was to demonstrate that endoscopic nerve blocks, using a mixture of bupivicaine and triamcinolone-40, injected into the anterior ethmoid or sphenopalatine regions, can be a relative safe and effective option for refractory pain. METHODS: The charts of all patients undergoing endoscopic neural blockade, in a private practice setting from 1998 to 2008 were retrospectively reviewed. A 1:1 mixture of 0.5% bupivicaine and triamcinolone acetonide injectable suspension was injected into the patients’ anterior ethmoid or sphenopalatine neural distribution, or both, depending on the pain distribution. Charts were reviewed to assess outcomes and any adverse events from nerve blocks. RESULTS: A total of 882 nerve blocks were administered to 147 patients, over the course of 431 office visits. Four mild complications, 2 moderate complications, and no severe or permanent complications were noted. No permanent visual complications were observed. Of all the charts, 85% had documented effects of the nerve block at follow-up. Of those, 81.3% claimed improvement, 17.9% reported feeling the same, and 0.79% stated they had worse pain. CONCLUSION: Endoscopic neural blockade appears to be a relatively safe and viable option in the treatment of refractory headache and facial pain with a rhinogenic component. Copyright © 2012 American Rhinologic Society-American Academy of Otolaryngic Allergy, LLC. Am J Rhinol Allergy. 2012 Jan-Feb;26(1):e23-7. doi: 10.2500/ajra.2012.26.3709. Bilateral sphenopalatine ganglion blockade improves postoperative analgesia after endoscopic sinus surgery. DeMaria S Jr1, Govindaraj S, Chinosorvatana N, Kang S, Levine AI. Author information Abstract BACKGROUND: Endoscopic sinus surgery (ESS) is a common procedure preferably done with an anesthetic technique ensuring effective postoperative analgesia while speeding discharge home. Although anesthesia administered locally in conjunction with vasoconstricting agents is known to minimize intraoperative bleeding, its usefulness in providing postoperative analgesia has not been well characterized. The results supporting the use of regional anesthesia for sinus surgery have also been limited. Using a randomized, double-blinded and placebo-controlled design, we evaluated recovery times, opioid consumption, and nausea and vomiting after ESS when patients were randomized to either general anesthesia (GA) alone or with regional blockade. METHODS: Subjects were 70 adults scheduled for sinus surgery. All participants underwent propofol/remifentanil/nitrous oxide anesthesia and similar intraoperative care. Patients received either GA alone or with sphenopalatine ganglion (SPG) blocks in a double-masked study design. Independent observers recorded readiness for discharge, incidence of nausea/vomiting, and pain scores every 15 minutes until discharge. Overall opioid use in the recovery area was also a secondary end point. Twenty-four hours later, patients were called and asked to rate their pain and overall satisfaction with their pain control. RESULTS: Block group participants were considered ready for discharge after 45 minutes and discharged from the hospital ∼40 minutes sooner than GA group participants. The block group required less total fentanyl in the recovery room than did the GA group. The incidences of nausea and vomiting did not differ significantly. Data at 24 hours postoperatively did not differ significantly between groups but trended toward increased satisfaction in the block group. No lasting adverse events were observed. CONCLUSION: Regional anesthesia using targeted nerve blocks is effective in ESS. The combination of GA and SPG blockade appears to shorten hospital stay and reduce narcotic requirements in the recovery area. No demonstrable benefits were observed after 24 hours regarding pain management. PMID: 22391074 [PubMed – indexed for MEDLINE] Neurol Sci. 2010 Jun;31 Suppl 1:S197-9. doi: 10.1007/s10072-010-0325-2. Sphenopalatine endoscopic ganglion block in cluster headache: a reevaluation of the procedure after 5 years. Pipolo C1, Bussone G, Leone M, Lozza P, Felisati G. Author information Abstract Cluster headache (CH) is considered the most painful form of primary headaches. It is characterized by severe unilateral pain, typically associated with autonomic manifestations and may be divided into an episodic and a chronic form. The latter is often resistant to a multitude of medication and is, therefore, very hard to treat. In 2002, our group developed a technique for the endoscopic sphenopalatine ganglion block that was able to ameliorate the symptoms in 55% of drug-resistant chronic CH patients. This paper is intended as an update on the technique as well as a comparison in effectiveness to our prior approach. PMID: 20464621 [PubMed – indexed for MEDLINE] Neurotherapeutics. 2010 Apr;7(2):197-203. doi: 10.1016/j.nurt.2010.03.001. Nerve blocks in the treatment of headache. Levin M. Author information Abstract Nerve blocks and neurostimulation are reasonable therapeutic options in patients with head and neck neuralgias. In addition, these peripheral nerve procedures can also be effective in primary headache disorders, such as migraine and cluster headaches. Nerve blocks for headaches are generally accomplished by using small subcutaneous injections of amide-type local anesthetics, such as lidocaine and bupivicaine. Targets include the greater occipital nerve, lesser occipital nerve, auriculotemporal nerve, supratrochlear and supraorbital nerves, sphenopalatine ganglion, cervical spinal roots, and facet joints of the upper cervical spine. Although definitive studies examining the usefulness of nerve blocks are lacking, reports suggest that this area deserves further attention in the hope of acquiring evidence of effectiveness. Copyright 2010 The American Society for Experimental NeuroTherapeutics, Inc. Published by Elsevier Inc. All rights reserved. PMID: 20430319 [PubMed – indexed for MEDLINE] Laryngoscope. 2006 Aug;116(8):1447-50. Sphenopalatine endoscopic ganglion block: a revision of a traditional technique for cluster headache. Felisati G1, Arnone F, Lozza P, Leone M, Curone M, Bussone G. Author information Abstract The diagnosis of chronic cluster headache (CH), the most painful form of headache, is based on typical clinical features characterized by strictly unilateral pain with no side shift and ipsilateral oculofacial autonomic phenomena. The attacks occur several times a day for periods of 1 to 2 months in the episodic form of the disease or less frequently on a daily basis in the chronic form. The pathogenesis of CH involves the activation of parasympathetic nerve structures located within the sphenopalatine ganglion (SPG), which explains many of the associated symptoms, whereas the activation of the ipsilateral hypothalamic gray matter may explain its typical circadian and circannual periodicity. A number of surgical approaches have been tried in cases of chronic CH resistant to pharmacologic therapy, of which SPG blockade has been shown to have certain efficacy. We have adopted a new technique based on endoscopic ganglion blockade that approaches the pterigo-palatine fossa by way of the lateral nasal wall and consists of the injection of a mixture of local anesthetics and corticosteroids, which was performed in 20 selected patients with chronic CH, according to the International Headache Society criteria (18 male, 2 female; mean age 40 yr), who were selected for SPG blockade because they were totally drug resistant. The symptoms improved significantly, but always only temporarily, in 11 cases. These results should be considered rather good because, unlike other frequently used techniques, SPG blockade is not invasive and should therefore always be attempted before submitting patients to more invasive surgical approaches. PMID: 16885751 [PubMed – indexed for MEDLINE] Br J Anaesth. 2006 Oct;97(4):559-63. Epub 2006 Aug 1. Intranasal lidocaine 8% spray for second-division trigeminal neuralgia. Kanai A1, Suzuki A, Kobayashi M, Hoka S. Author information Abstract BACKGROUND: Trigeminal nerve block has been widely used for trigeminal neuralgia. This may induce paraesthesia. The second division of the trigeminal nerve passes through the sphenopalatine ganglion, which is located posterior to the middle turbinate and is covered by a mucous membrane. We examined the effectiveness of intranasal lidocaine 8% spray on paroxysmal pain in second-division trigeminal neuralgia. METHODS: Twenty-five patients with second-division trigeminal neuralgia were randomized to receive two sprays (0.2 ml) of either lidocaine 8% or saline placebo in the affected nostril using a metered-dose spray. After a 7 day period, patients were crossed over to receive the alternative treatment. The paroxysmal pain triggered by touching or moving face was assessed with a 10 cm visual analogue scale (VAS) before and 15 min after treatment. Patients used a descriptive scale to grade pain outcome, and were asked to note whether the pain returned and how long after therapy it recurred. RESULTS: Intranasal lidocaine 8% spray significantly decreased VAS [baseline: 8.0 (2.0) cm, 15 min postspray: 1.5 (1.9) cm, mean (SD)], whereas the placebo spray did not [7.9 (2.0) cm, 7.6 (2.0) cm]. Moreover, pain was described as moderate or better by 23 patients of the lidocaine spray and 1 of the placebo group. The effect of treatment persisted for 4.3 h (range 0.5-24 h). CONCLUSIONS: Intranasal lidocaine 8% administered by a metered-dose spray produced prompt but temporary analgesia without serious adverse reactions in patients with second-division trigeminal neuralgia. Comment in Lidocaine intranasal spray for treatment of trigeminal neuralgia. [Br J Anaesth. 2007] S Headache. 1999 Jan;39(1):42-4. Sphenopalatine ganglion block for treatment of sinus arrest in postherpetic neuralgia. Saberski L1, Ahmad M, Wiske P. Author information Abstract A 64-year-old woman presented with bradycardia from sinus pauses during exacerbations of postherpetic trigeminal distribution neuralgia. She had underlying systemic lupus erythematosus. Sphenopalatine ganglion blockade was employed to treat her pain. The episodes of bradycardia resolved with successful alleviation of pain. This report emphasizes that a sphenopalatine ganglion blockade can be employed in the treatment and prevention of sinus arrest associated with postherpetic trigeminal distribution neuralgia. Cranio. 2001 Jan;19(1):48-55. Anatomically and physiologically based guidelines for use of the sphenopalatine ganglion block versus the stellate ganglion block to reduce atypical facial pain. Klein RN1, Burk DT, Chase PF. Author information Abstract This literature review is designed to develop guidelines needed for the use of a sphenopalatine ganglion block versus a stellate ganglion block to reduce atypical facial pain. We have reviewed the basic anatomy of both ganglia and the physiological responses usually associated with each, and have given an opinion on appropriate use of these therapeutic modalities. PMID: 11842841 [PubMed – indexed for MEDLINE] Anaesthesia. 2001 Jun;56(6):606-7. A new interest in an old remedy for headache and backache for our obstetric patients: a sphenopalatine ganglion block. Cohen S, Trnovski S, Zada Y. Comment in Sphenopalatine ganglion block for postdural puncture headache. [Anaesthesia. 2009] PMID: 11412202 [PubMed – indexed for MEDLINE] Reg Anesth Pain Med. 1998 Jan-Feb;23(1):30-6. Sphenopalatine ganglion block for the treatment of myofascial pain of the head, neck, and shoulders. Ferrante FM1, Kaufman AG, Dunbar SA, Cain CF, Cherukuri S. Author information Abstract BACKGROUND AND OBJECTIVES: This study examined the effectiveness of sphenopalatine ganglion block (SPGB) for myofascial pain syndrome of the head, neck, and shoulders using a double-blind, placebo-controlled, crossover study design with comparison to an internal standard consisting of trigger point injections (TPI). METHODS: Patients (n = 23) were randomly assigned to receive either: (1) SPGB with 4% lidocaine, then TPI with 1% lidocaine, and finally SPGB with saline placebo or (2) SPGB with saline placebo, then TPI with 1% lidocaine, and finally SPGB with 4% lidocaine. Each respective treatment within each protocol was given sequentially at 1-week intervals for both groups. Prior to the first treatment, all patients assessed their average intensity of pain and pain at that particular moment using a visual analog pain scale. Pain intensity and pain relief were reassessed 30 minutes after each treatment and at 6 hours, 24 hours and 1 week using visual analog pain and pain relief scales. Pain intensity and pain relief data were transformed into natural logarithm units, and the statistical significance of SPGB with 4% lidocaine versus SPGB with placebo, SPGB with 4% lidocaine versus TPI, and TPI versus SPGB with placebo were tested by mixed-model analysis of variance. The magnitude of the differences in pain intensity and pain relief ratings were also compared via computation of 95% confidence intervals. RESULTS: The analgesic effect of SPGB with 4% lidocaine was no better than placebo. Mixed-model analysis of variance revealed improved analgesia with administration of TPIs as compared to SPGB with 4% lidocaine and placebo over the entire week of observations (pain relief scores). CONCLUSIONS: This study suggests that SPGB with 4% lidocaine is no more efficacious than placebo and less efficacious than administration of standard trigger point injections in the treatment of myofascial pain of the head, neck, and shoulders. PMID: 9552776 [PubMed – indexed for MEDLINE] Indian J Otolaryngol Head Neck Surg. 1998 Jan;50(1):99-105. doi: 10.1007/BF02996789. Endoscopic sphenopalatine ganglion block for pain relief. Murty PS1, Prasanna A. Author information Abstract The anaesthetic effect of the sphenopalatine (SPG) block has been well utilized for intranasal topical anaesthesia but the analgesic efficacy of (SPG) block, though well documented in literature, has not been put into practice. The methods available for SPG block till date were blind as they do not visualize the foramen. Nasal endoscopies have been used to visualize the foramen for an effective block. The authors present their experience with the endoscopic sphenopalatine ganglion block for pain relief in head and neck malignancies and neuralgias. PMID: 23119393 [PubMed] PMCID: PMC3451247 Free PMC Article J Neurosurg. 1997 Dec;87(6):876-80. Efficacy of sphenopalatine ganglion blockade in 66 patients suffering from cluster headache: a 12- to 70-month follow-up evaluation. Sanders M1, Zuurmond WW. Author information Abstract This study was conducted to evaluate the efficacy, based on 12- to 70-month follow-up data, of radiofrequency (RF) lesions of the sphenopalatine ganglion made in patients suffering from cluster headache. Sixty-six patients suffering from either episodic (Group A, 56 patients) or chronic (Group B, 10 patients) cluster headache who were not responsive to pharmacological management were treated by RF lesioning in the sphenopalatine ganglion. Complete relief of pain was achieved in 34 (60.7%) of 56 patients in Group A and in three (30%) of 10 patients in Group B. No relief was found in eight patients (14.3%) in Group A and in four (40%) in Group B. The mean time of follow up was 29.1 +/- 10.6 months in Group A and 24 +/- 9.7 months in Group B, ranging from 12 to 70 months. With regard to side effects and complications, temporary postoperative epistaxis was observed in eight patients and a cheek hematoma in 11 patients; a partial RF lesion of the maxillary nerve was inadvertently made in four patients. Nine patients complained of hypesthesia of the palate, which disappeared in all cases within 3 months. The authors conclude that RF lesioning in the sphenopalatine ganglion via the infrazygomatic approach may be performed in patients suffering from cluster headache that does not respond to pharmacological therapy. PMID: 9384398 [PubMed – indexed for MEDLINE] Laryngoscope. 1997 Oct;107(10):1420-2. Sphenopalatine blocks in the treatment of pain in fibromyalgia and myofascial pain syndrome. Janzen VD1, Scudds R. Author information Abstract Sphenopalatine blocks have been used to treat pain for more than 80 years. Anecdotal support for sphenopalatine ganglion blocks has been very strong in those who believe in the technique, but the research results have been inconclusive. Therefore, a double blind, placebo-controlled study was performed on 61 patients, 42 with fibromyalgia and 19 with myofascial pain syndrome. Pain was measured using visual analogue scales prior to treatment, during treatment, and 28 days after the treatment. Headaches were evaluated in frequency and location prior to and after treatment. Sphenopalatine ganglion blocks were performed under direct vision using 4% lidocaine and sterile water as a placebo. Analysis of the results showed no statistical differences between the lidocaine and the placebo groups. PMID: 9331324 [PubMed – indexed for MEDLINE] J Pain Symptom Manage. 1997 Jun;13(6):332-8. Vasomotor rhinitis and sphenopalatine ganglion block. Prasanna A1, Murthy PS. Author information Abstract The effectiveness of the sphenopalatine ganglion (SPG) block for the relief of symptoms in chronic vasomotor rhinitis was assessed in 30 patients of both genders. The number of blocks required for complete relief was three (range from two to four) at weekly intervals in 66.7% of volunteers. There was no recurrence of symptoms during a follow-up period of 12-20 months in 29 patients, and one patient was symptom free for 8 months. The technique is simple and can be performed as an outpatient procedure without side effects. PMID: 9204653 [PubMed – indexed for MEDLINE] Nebr Med J. 1996 Sep;81(9):306-9. Sphenopalatine ganglion block relieves symptoms of trigeminal neuralgia: a case report. Manahan AP1, Malesker MA, Malone PM. Author information Abstract A 56 year old, white female with a diagnosis of trigeminal neuralgia, unresponsive to medical therapy, received a sphenopalatine ganglion block using bupivacaine 0.5%. A total of ten treatments were given. The patient remained pain free as of 30 months after initial treatment. This treatment appears to be effective and deserves further study. PMID: 8885638 [PubMed – indexed for MEDLINE] Reg Anesth. 1996 Jan-Feb;21(1):68-70. Patient-administered sphenopalatine ganglion block. Saade E1, Paige GB. Author information Abstract BACKGROUND AND OBJECTIVES: Pain resulting from head and neck cancer can be severe and difficult to manage. Avoiding hospitalization for as long as possible with a reasonable level of comfort requires a number of therapeutic modalities. The usefulness of self-administered sphenopalatine ganglion block was evaluated in a patient with lethal midline granuloma requiring large doses of morphine. METHODS: A 30-year-old woman with intractable pain from lethal midline granuloma was taught to self-administer 4% lidocaine, 1.5 mL topically into each nostril three times per day. RESULTS: A 3-month follow-up examination showed substantial pain relief and reduction in morphine requirement. No adverse side effects or complications developed. CONCLUSIONS: In certain patients, sphenopalatine ganglion block can be effectively self-administered at home to manage chronic pain. PMID: 8826027 [PubMed – indexed for MEDLINE] Can Nurse. 1991 Oct;87(9):33-5. [Cluster headaches]. [Article in French] Grégoire PC. Abstract After taking a second look at a treatment that was common in 1933 for victims of cluster headaches, a doctor from Lieges, Belgium, is now training anesthesiologists in the technique of alcoholization of the sphenopalatine ganglion. The solution is filtered in through the supra-zygomatic channel. Cluster headaches, which are six times more likely to strike men than women, can last anywhere from a few minutes to several hours, affecting the patient’s quality of life. The pain has been described as burning, piercing, penetrating, cutting and pounding. The author defines the illness, describes the symptoms and the predisposing conditions. The article gives an overview of the newly rediscovered treatment, that is making inroads in Europe. Other points include : a brief anatomy lesson, an explanation of the technique, proper positioning of patients, preparation of the solution and the nurse’s role in the treatment. South Med J. 1988 Jul;81(7):832-6. Sphenopalatine ganglion blocks for the treatment of nicotine addiction. Henneberger JT1, Menk EJ, Middaugh RE, Finstuen K. Author information Abstract The purpose of this study was to investigate the effects of sphenopalatine ganglion block upon the physical symptoms of nicotine withdrawal in a double-blind placebo-controlled study. Seventeen patients completed a course of treatment which involved daily intranasal application of local anesthetic (bupivacaine or cocaine) or saline over the sphenopalatine ganglion. The reported numbers of daily symptoms of physical discomfort were recorded during the preprocedure period. Analysis of variance results indicated that patients in all three groups experienced a significant decline in the number of symptoms of physical discomfort over the six-day withdrawal period. Further findings provided evidence of significantly fewer symptoms of discomfort for patients in the anesthetic treatment groups than in the placebo control group, though no statistically significant difference emerged between the two anesthetic treatment groups. Accelerated alleviation of discomfort during nicotine withdrawal may increase the success of smoking cessation. Acta Anaesthesiol Belg. 1981;32(1):101-7. Cluster headache and sphenopalatine block. Devoghel JC. Abstract 1. Cluster headache is a severe unilateral head or facial pain, which lasts for minutes or hours, commonly associated with ipsilateral lacrimation and blockade of the nostril. It usually recurres once or more daily for a period of weeks or months, separated by intervals of freedom. The sphenopalatine ganglion seems to play a very important role in its pathology, 2. We created a technic of alcohol infiltration of this ganglion through a supra-zygomatic way, based on the research of the maxillary nerve by neurostimulation and the bone contact with the pterygoid process. 3. We observed a relief of pain and parsympathetic disturbances in more than 85% of our 120 cases, with a follow up between 6 months and 4 years. 4. Results obtained are discussed and analysed in connection with the definition of cluster headache. (Acta anaesth. belg., 1981, 32, 101-107). PMID: 7293708 [PubMed – indexed for MEDLINE] N Y State J Med. 1948 Nov 15;48(22):2475-80. Sphenopalatine ganglion block for the relief of painful vascular and muscular spasm with special reference to lumbosacral pain. AMSTER JL. PMID: 18890612 [PubMed – OLDMEDLINE] Neuromodulation in cluster headache. Fontaine D1, Vandersteen C, Magis D, Lanteri-Minet M. Author information Abstract Medically refractory chronic cluster headache (CH) is a severely disabling headache condition for which several surgical procedures have been proposed as a prophylactic treatment. None of them have been evaluated in controlled conditions, only open studies and case series being available. Destructive procedures (radiofrequency lesioning, radiosurgery, section) and microvascular decompression of the trigeminal nerve or the sphenopalatine ganglion (SPG) have induced short-term improvement which did not maintain on long term in most of the patients. They carried a high risk of complications, including severe sensory loss and neuropathic pain, and consequently should not be proposed in first intention.Deep brain stimulation (DBS), targeting the presumed CH generator in the retro-hypothalamic region or fibers connecting it, decreased the attack frequency >50 in 60 % of the 52 patients reported. Complications were infrequent: gaze disturbances, autonomic disturbances, and intracranial hemorrhage (2).Occipital nerve stimulation (ONS) was efficient (decrease of attack frequency >50 %) in about 70 % of the 60 patients reported, with a low risk of complications (essentially hardware related). Considering their respective risks, ONS should be proposed first and DBS only in case of ONS failure.New on-demand chronically implanted SPG stimulation seemed to be efficient to abort CH attacks in a pilot controlled trial, but its long-term safety needs to be further studied.
PMID: 25411142 [PubMed – in process]
Neuromodulation in cluster headache.
Fontaine D1, Vandersteen C, Magis D, Lanteri-Minet M.
Medically refractory chronic cluster headache (CH) is a severely disabling headache condition for which several surgical procedures have been proposed as a prophylactic treatment. None of them have been evaluated in controlled conditions, only open studies and case series being available. Destructive procedures (radiofrequency lesioning, radiosurgery, section) and microvascular decompression of the trigeminal nerve or the sphenopalatine ganglion (SPG) have induced short-term improvement which did not maintain on long term in most of the patients. They carried a high risk of complications, including severe sensory loss and neuropathic pain, and consequently should not be proposed in first intention.Deep brain stimulation (DBS), targeting the presumed CH generator in the retro-hypothalamic region or fibers connecting it, decreased the attack frequency >50 in 60 % of the 52 patients reported. Complications were infrequent: gaze disturbances, autonomic disturbances, and intracranial hemorrhage (2).Occipital nerve stimulation (ONS) was efficient (decrease of attack frequency >50 %) in about 70 % of the 60 patients reported, with a low risk of complications (essentially hardware related). Considering their respective risks, ONS should be proposed first and DBS only in case of ONS failure.New on-demand chronically implanted SPG stimulation seemed to be efficient to abort CH attacks in a pilot controlled trial, but its long-term safety needs to be further studied.
PMID: 25411142 [PubMed – in process]
Additional References on SPG Blocks or Sphenopalatine Ganglion Blocks from The Sphenopalatine Ganglion (SPG) and Headache Disorders, Part II from http://www.achenet.org/resources/the_sphenopalatine_ganglion_spg_and_headache_disorders_part_ii/
Piagkou, M; Demesticha, T; Troupis, T; Vlasis, K; Skandalakis, P; Makri, A; Mazarakis, A; Lappas, D; Piagkos, G; Johnson, EO. “The pterygopalatine ganglion and its role in various pain syndromes: from anatomy to clinical practice.” Pain Pract. 2012;12(5):399-412.
Jenkin,s B; Tepper, SJ. “Neurostimulation for Primary Headache Disorders, Part 1: Pathophysiology and Anatomy, History of Neuromodulation in Headache Treatment, and Review of Peripheral Neuromodulation in Primary Headaches.” Headache 2011;51:1254-1266.
Martelletti, P; Jensen, RH; Antal, A; Arcioni, R; Brighina, F’ de Tommaso, M; Franzini, A; Fontaine, D; Heiland, M; Jürgens, TP; Leone, M; Magis, D; Paemeleire, K; Palmisani, S; Paulus, W; May, A. “Neuromodulation of chronic headaches: position statement from the European Headache Federation.” J Headache Pain 2013;14(1):86.
Khan, S; Schoenen, J; Ashina, M. “Sphenopalatine ganglion neuromodulation in migraine: What is the rationale?” Cephalalgia 2014;34(5:382–391.
Schoenen, J; Jensen, RH; Lantéri-Minet, M; Láinez, MJ; Gaul, C; Goodman, AM; Caparso, A; May, A. “Stimulation of the sphenopalatine ganglion (SPG) for cluster headache treatment. Pathway CH-1: a randomized, sham-controlled study.” Cephalalgia. 2013 Jul;33(10):816-30.
The following is a clinical trial currently enrolling participants comparing Elavil to SPG Blocks for treating Transformed Migraine.
Sphenopalatine Ganglion Nerve Block vs. Elavil for Treatment of Transformed Migraines