Sphenopalatine Ganglion Blocks Research Articles

Sequential administration of peripheral nerve blocks andonabotulinumtoxinA for the treatment of chronic migraine andother headache disorders-A retrospective tolerability and safety study.

To determine the tolerability and safety of concurrent peripheral nerve blocks and onabotulinumtoxinA treatment during a single outpatient clinic procedure visit. Procedural interventions are available for the treatment of headache disorders. OnabotulinumtoxinA and peripheral nerve blocks are used as alternatives or in addition to oral therapies to reduce the frequency and intensity of migraine attacks. There is currently a lack of safety data focusing on the sequential administration of local anesthetic via peripheral nerve blocks and onabotulinumtoxinA during a single clinical encounter for the treatment of headache. The primary aim of the study was to determine the safety and tolerability of concurrent peripheral nerve blockade and onabotulinumtoxinA injections during a single outpatient clinic procedure visit. We hypothesized that the dual intervention would be safe and well tolerated by patients with chronic migraine and other headache disorders. A retrospective chart review was performed using clinical data from patients seen by multiple providers over a 16-month timeframe at one outpatient headache clinic. Patients were identified by procedure codes and those receiving peripheral nerve block(s) and onabotulinumtoxinA injections during a single encounter within the study period were eligible for inclusion. Inclusion criteria were (1) patients 18 years and older who were (2) receiving both peripheral nerve blocks and onabotulinumtoxinA injections for the treatment of chronic migraine. Patients were excluded if they were under age 18, received their procedure outside of the clinic (emergency room, inpatient ward), or were receiving sphenopalatine ganglion blocks. Age- and sex-matched patients who received one procedure, either peripheral nerve blocks or onabotulinumtoxinA, were used for control. The primary outcome of this safety study was the number of adverse events that occurred in the dual intervention group compared to the single intervention control arms. Information regarding adverse events was gathered via retrospective chart review. If an adverse event was recorded, it was then graded by the reviewer utilizing the Common Terminology Criteria for Adverse Events ranging from Grade 1 Mild Event to Grade 5 Death. Additionally, it was noted whether the adverse event led to treatment discontinuation. In total, 375 patients were considered eligible for inclusion in the study. After age and sex matching of controls, 131 patients receiving dual intervention were able to be compared to 131 patients receiving onabotulinumtoxinA alone and 104 patients receiving dual intervention were able to be compared to 104 patients receiving peripheral nerve block(s) alone. The primary endpoint analysis showed no significant difference in total adverse events between dual intervention compared to nerve blocks alone or onabotulinumtoxinA alone. The number of adverse events that led to treatment discontinuation approached but did not reach statistical significance for those receiving dual intervention versus onabotulinumtoxinA alone in the number of adverse events that led to treatment termination (4.6%, 6/131 vs. 0.8%, 1/131, p = 0.065); however, the number of patients who discontinued therapy was not significantly different between those groups (2.3%, 3/131 vs. 0.8%, 1/131; p = 0.314; odds ratio 0.3 [0-3.2]; p = 0.338). In this retrospective chart review, there was no significant difference in adverse events or therapy discontinuation between patients receiving sequential peripheral nerve block(s) and onabotulinumtoxinA injections versus those receiving either peripheral nerve block(s) or onabotulinumtoxinA injections alone. As a result, we concluded that the combination procedure is likely safe and well tolerated in routine clinical practice.

Sphenopalatine ganglion block with lidocaine versus bupivacaine for optimizing intraoperative bleeding and surgical field visibility during endoscopic septoplasty: a randomized double-blind controlled trial

Background & objective: The benefits of sphenopalatine ganglion (SPG) block during endoscopic septoplasty are yet unclear due to a lack of adequate data. We investigated the efficacy of SPG block (SPGB) with lidocaine versus bupivacaine for minimizing intraoperative bleeding and providing a bloodless surgical field in patients having endoscopic septoplasty under general anesthesia. Methodology: In this double-blind, randomized controlled trial, 60 patients with ASA I and II were scheduled for endoscopic septoplasty. Following standard general anesthesia, patients were randomly assigned to one of three groups. Group C (n = 20): SPGB was performed using normal saline in the control group; Group L (n = 20); patients received SPGB with 2% lidocaine, and Group B (n = 20); patients received SPGB with 0.5% bupivacaine. Intraoperative blood loss, surgical field quality, postoperative pain-free duration, postoperative analgesic requirements, and the patient satisfaction were recorded. The collected data were verified, coded by the researcher, and analyzed using the Statistical Package for Social Sciences (IBM-SPSS/PC/VER 21). Statistical analysis was done with the Shapiro-Wilk test, one-way ANOVA test and two-way repeated measure ANOVA test as required. The Kaplan–Meier curve was plotted to explore the differences in the post-operative pain-free durations among the studied groups using the log-rank test. A p-value less than 0.05 was considered significant. Results: The intraoperative blood loss and surgical field grading were lower in the groups treated with lidocaine (44.9 ± 3.7 ml, P < 0.001) or bupivacaine (41.4 ± 2.9 ml, P < 0.001) in comparison to the control group (89.95 ± 7.8 ml). There was no difference between the two groups. Postoperative meperidine requirement in 24 h was higher in the control group (36.25 ± 2.9 mg) than the lidocaine group (18.75 ± 2.5 mg; P < 0.001) and the bupivacaine group (16.25 ± 2.7 mg; P < 0.001). Conclusion: Sphenopalatine ganglion blockade with bupivacaine or lidocaine decreased intraoperative blood loss and improved surgical field visibility compared to placebo during endoscopic septoplasty under general anesthesia. There were statistically no significant differences in sphenopalatine ganglion blocks with either lidocaine or bupivacaine. Abbreviations: SPG- Sphenopalatine Ganglion; SPGB- Sphenopalatine Ganglion Block; VAS- Visual Analog Scale Keywords: Bupivacaine; Endoscopic Septoplasty; Lidocaine; Postoperative Analgesia; Sphenopalatine Ganglion Block Citation: Ghazaly HF, Khalefa MM, Sedeek MA, Hasanen MK. Sphenopalatine ganglion block with lidocaine versus bupivacaine for optimizing intraoperative bleeding and surgical field visibility during endoscopic septoplasty: a randomized double-blind controlled trial. Anaesth. pain intensive care 2024;28(1):92-99; DOI: 10.35975/apic.v28i1.2393 Received: August 29, 2023; Reviewed: December 29, 2023; Accepted: December 31, 2023

Sphenopalatine Ganglion Block Using Intranasal Lignocaine Spray for Trigeminal Neuralgia: A Case Series

Abstract Various interventions have been tried for the management of trigeminal neuralgia which is a sharp, shooting recurrent neuropathic pain. The use of the sphenopalatine ganglion (SPG) block has been established as a fast, safe, and effective means of pain relief for these patients. Recently, 10% lignocaine spray has been described as a less invasive alternative for this block. We report seven patients of idiopathic trigeminal neuralgia with acute unilateral severe pain managed by SPG blocks using 10% intranasal lignocaine spray. Seven patients with unilateral trigeminal neuralgia were included in the study. Two puffs of 10% lignocaine were sprayed into the nostril of the affected side in a slightly medial and inferior direction. Before the procedure and 30 min later, Visual Analog Scale (VAS) scoring was done. The procedure was repeated in case of no pain relief after 1 h of nasal spray (VAS 4 or 5). All patients were observed for 2 h and oral medication was prescribed if required after assessment at 24 h. Four patients reported complete relief (VAS 0 or 1) and two of them reported pain (VAS 4 and 5) after 24 h. The procedure had to be repeated in two patients with no pain relief (VAS 4 and 5) after 1 h. There was no relief in one patient even after repeated administration (VAS 5). The findings suggest a role for intranasal lignocaine spray for SPG block in trigeminal neuralgia for alleviating acute exacerbations of pain and obtaining quick relief.

Optimizing techniques for in-office endoscopic transnasal sphenopalatine ganglion block injections

Otolaryngologists play a central role in diagnosing and treating facial pain syndromes and headache disorders. Although sphenopalatine ganglion block is a recognized treatment option, literature on transnasal injection techniques is limited. This study's objective is to refine anatomic landmarks and optimize a technique for in-office transnasal sphenopalatine ganglion blocks. Eight cadaveric head specimens were dissected to record sixteen measurements of critical anatomic landmarks and surgical instruments for sphenopalatine ganglion block. On average, the sphenopalatine foramen center was 5.94 mm (±1.65 mm) superior to the inferior border of the middle turbinate's basal lamella attachment to the lateral nasal wall. We describe the reliability of using a 20G spinal needle bent at 70-degrees to perform a transnasal injection technique for sphenopalatine ganglion block. The inferior border of the middle turbinate basal lamella attachment to the lateral nasal wall may be used as an intranasal landmark in transnasal injection of the sphenopalatine ganglion. Further testing in the clinical setting is required to assess efficacy.

Sphenopalatine Ganglion Block for Postacute Sequelae SARS-CoV-2 Infection Headaches: A Case Report and Review of the Literature

BACKGROUND: In a subset of patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), neurological symptoms including “brain fog” and headache persist beyond the acute phase of the infection, often referred to as postacute sequelae SARS-CoV-2 infection (PASC), or Long COVID. Current practice supports a multi-modal approach to address PASC symptoms. One technique for chronic headaches not utilized for PASC is sphenopalatine ganglion blocks (SPGB). We evaluate the pathophysiology of PASC headaches, review the utilization of sphenopalatine ganglion blocks in primary headaches, and discuss the potential for SPGB in PASC headaches. CASE REPORT: We present a patient with PASC headaches who failed various conservative and interventional therapies. Worsening symptoms resulted in pursuing bilateral SPGB, resulting in an 80% improvement in symptoms. To our knowledge, we report the first PASC headache treated with an SPGB via infrazygomatic injection. CONCLUSION: SPGB can treat PASC headaches and improve a patient’s quality of life. KEY WORDS: Sphenopalatine ganglion block, Long COVID, PASC, headaches, case report

Bilateral Sphenopalatine Ganglion Blocks for Refractory Burning Mouth Syndrome

BACKGROUND: Burning mouth syndrome (BMS) is a debilitating condition that produces a burning pain of the oral cavity and does not have identifiable inciting factors. There are no established treatments, but neuropathic medications have been trialed with variable efficacy. Utilizing targeted nerve blocks could provide therapeutic benefit when treating patients with refractory BMS symptoms. CASE REPORT: This case describes the treatment of a 61-year-old woman with BMS who presents with refractory symptoms despite maximum dose trials of neuropathic medications. She was successfully treated using bilateral sphenopalatine ganglion blocks. The patient reported a decrease in pain from 7/10 to 1/10 one day after the procedure and described a 90% benefit. CONCLUSIONS: Bilateral sphenopalatine ganglion blocks should be considered to treat refractory BMS. KEY WORDS: Refractory burning mouth syndrome, burning tongue, stomatodynia, nerve block, local anesthesia, pain management

Bilateral Sphenopalatine Ganglion Block for the Treatment of Post Dural Puncture Headache: A Case Report

Background: Post dural puncture headache (PDPH) is a known and potentially debilitating complication of neuraxial anesthesia that can impede patient recovery. The conventional treatment includes hydration and symptomatic treatment like simple analgesics. Those who have unremitting symptoms following conservative measures are offered an epidural blood patch (EBP). However, EBP, an invasive procedure, is associated with complications in itself. Case: We report a 40-year-old man who experienced PDPH after spinal anesthesia. His symptoms recurred after conservative management was instituted. He was then offered a trans-nasal sphenopalatine ganglion (SPG) block. He had excellent pain relief and did not require an EBP. Conclusion: SPG blocks can be considered early in the treatment of PDPH together with general supportive measures. However, if pain relief is not achieved, an epidural blood patch should still be considered.

Percutaneous Interventional Strategies for Migraine Prevention: A Systematic Review and Practice Guideline.

To systematically evaluate the efficacy and effectiveness of percutaneous interventional treatments for prevention of migraine through a qualitative and (when possible) quantitative analysis. An expert panel was asked to develop recommendations for the multidisciplinary preventive treatment of migraine, including interventional strategies. The committee conducted a systematic review and (when evidence was sufficient) a meta-analytic review by using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria and the modified Cochrane Risk of Bias analysis available in the Covidence data management program. Clinical questions addressed adults with migraine who should be offered prevention. Examined outcomes included headache days, acute medication use, and functional impairment. Acute management of migraine was outside the scope of this guideline. The committee screened 1,195 studies and assessed 352 by full text, yielding 16 randomized controlled trials that met the inclusion criteria. As informed by evidence related to the preselected outcomes, adverse event profile, cost, and values and preferences of patients, onabotulinumtoxinA received a strong recommendation for its use for chronic migraine prevention and a weak recommendation against its use for episodic migraine prevention. Greater occipital nerve blocks received a weak recommendation for their use for chronic migraine prevention. For greater occipital nerve block, steroid received a weak recommendation against its use vs the use of local anesthetic alone. Occipital nerve with supraorbital nerve blocks, sphenopalatine ganglion blocks, cervical spine percutaneous interventions, and implantable stimulation all received weak recommendations for their use for chronic migraine prevention. The committee found insufficient evidence to assess trigger point injections in migraine prevention and highly discouraged the use of intrathecal medication.

Transnasal Sphenopalatine Ganglion Block for the Preventive Treatment of Chronic Daily Headache in Adolescents.

Chronic headaches are a major source of morbidity in the pediatric population, affecting physical function, school attendance, social capacity, mood, and sleep. In adults, repetitive sphenopalatine ganglion (SPG) blockade has been studied as a preventive treatment for chronic migraines. This case series aims to evaluate the SPG block for the preventive treatment of chronic daily headache (CDH) in adolescents. We prospectively evaluated 17 adolescents (14 females, 14 ± 1 year) with CDH not responding to cognitive behavioral therapy (CBT), physiotherapy, and standard medications. Each patient received 10 SPG blocks (two blocks/week) using the Tx360® device. At the end of treatment, 10 patients (59%) reported a Patient’s Global Impression of Change (PGIC) score ≥ 67%, and 3 months after the end of treatment, nine patients (53%) sustained a PGIC ≥ 67%. There was also a statistically significant reduction in the depression subscale of the Revised Children’s Anxiety and Depression Scale (RCADS) at the end of treatment and 3 months post-treatment compared with baseline. The procedure was well tolerated with no adverse effects. In our study, the use of repeat SPG blockade was associated with sustained benefits on the PGIC and the depression subscale of the RCADS when used as preventive headache treatment in adolescents with refractory CDH.

Sphenopalatine Ganglion versus Greater Occipital Nerve Blocks in Treating Post-Dural Puncture Headache after Spinal Anesthesia for Cesarean Section: A Randomized Clinical Trial

Despite being invasive, with serious complications, epidural blood patch (EBP) is still considered the gold standard therapy for Post Dural Puncture Headache (PDPH). The use of Peripheral nerve blocks for PDPH are studied here. To investigate the efficacy of sphenopalatine ganglion block (SPGB) and greater occipital nerve block (GONB) to relieve PDPH and its associated symptoms. Randomized comparative single-blind trial. A University hospital. Patients who received spinal anesthesia for elective cesarean section, and then developed PDPH during hospitalization or within 5 days after dural puncture were enrolled to receive GONB (n = 47) or SPGB (n = 46) for treatment of PDPH. GONB Group: Patients received bilateral GONB using 3 mL mixture of 2 mL lidocaine 2% plus 1 mL dexamethasone 4 mg on each side of occipital region. SPGB Group: Patients received bilateral SPGB using the same mixture in each nostril. Assessments included Numeric Rating Scale (NRS) for severity of headache at supine and sitting positions, nausea NRS, neck stiffness, need for EBP, and complications. The supine and sitting headache NRS scores significantly decreased at 30 minutes after blocks and throughout follow-up period in both groups (P < 0.000). Clinically significant drop of NRS to < 4 was reached earlier in GONB group. There was a significant difference between groups after 2 hours in supine and sitting headache NRS scores (P = 0.020 and 0.030, respectively); however, both treatments showed similar effectiveness from the third hour afterwards (P > 0.05). Both techniques were effective in relieving neck stiffness and nausea (P < 0.000), with no adverse effects. A limitation to this study was the small sample size. GONB and SPGB are equally effective in relieving symptoms of PDPH. Both techniques are safe, simple, and less invasive than EBP.

Clinic-based Procedures for Headache.

Headache disorders are common and disabling, and many therapies that are effective and safe are procedural. After pivotal clinical trials, onabotulinumtoxinA has become an established preventive therapy for chronic migraine; it is better tolerated than many other treatments and may be useful for other headache disorders. Peripheral nerve blocks, especially greater occipital nerve blocks, have amassed evidence from randomized trials in the acute and short-term preventive treatment of migraine and cluster headache. Trigger point injections and sphenopalatine ganglion blocks have recent trials suggesting efficacy and safety in properly selected patients. Medical education initiatives are needed to train neurologists in these procedures to help manage the large population of patients with headache disorders who need them. Evidence exists for the efficacy and safety of procedural therapies to be incorporated into neurology practice for the management of patients with migraine, cluster headache, and other headache disorders.

A Computerized Tomographic and Cadaveric Study of Sphenopalatine Ganglion Block Via the Pterygomaxillary Fissure: Anatomical Considerations of the Suprazygomatic Approach

Background: The sphenopalatine ganglion (SPG) is a parasympathetic ganglion that’s implicated in multiple primary headache disorders. Current techniques are inconsistent or require imaging. A suprazygomatic approach is thought to be safe and effective. The main objectives are to determine an accurate depth and needle angulation to perform SPG blocks safely and effectively. Methods: Cranial computerized tomography was obtained from 40 Caucasians (20 male, 20 female). For each patient, a line is drawn from the frontozygomatic angle to the pterygomaxillary fissure (PMF) to represent length. Intersection of the line in both transverse and coronal Frankfurt planes create inferior and posterior angulations, respectively. A cadaver dissection is performed to validate the needle placement utilizing these measurements. Contrast fluoroscopy is utilized to verify needle placement in PMF. Results: The mean length was 24.9 +/- 2.8mm for males and 23.8 +/- 0.5mm for females. The difference was statistically significant (p = .019). In patients younger than 40 years, the mean length was 24.5 +/- 2.8mm. In patients greater than 40 years, the mean length was 26.1 +/- 3.1mm. The difference was statistically significant (p = .018). Both inferior and posterior angles were not statistically different between sex or age. Post-contrast imaging confirmed presence of dye in the PMF. Conclusion: While there is a difference in depth between sex and age groups, it’s likely not clinically significant. A depth of 25mm angulated at 6 degrees inferior and 27 degrees posterior is likely generalizable. Bony landmark-based, suprazygomatic SPG blocks via the PMF are probably feasible, safe with minimal risk and may be an option in special patient populations and/or circumstances.

Sphenopalatine Ganglion Nerve Block for the Treatment of Migraine Headaches in the Pediatric Population

BACKGROUND: Persistent headaches and migraines are common in pediatrics with various treatment options. The sphenopalatine ganglion (SPG) has been identified as communicating with the parasympathetic autonomic nervous system and pain receptors. In adults, SPG block is an established treatment but there is no published literature in pediatrics. OBJECTIVES: The purpose of this study is to analyze the SPG block in pediatrics. STUDY DESIGN: Retrospective, single-center study. SETTING: This study was conducted at Phoenix Children’s Hospital in Phoenix, Arizona. METHODS: A comprehensive review of patient charts from 2015–2018 of all pediatric SPG blockades performed by interventional radiology were included in the analysis. Utilizing fluoroscopic guidance, a SphenoCath was inserted into each nostril and after confirming position, and 4% lidocaine injected. Pre- and postprocedural pain was assessed using the Visual Analog Scale (VAS). Immediate and acute complications were documented. RESULTS: A total of 489 SPG blocks were performed in patients between ages 6 and 26 years who were diagnosed with migraine or status migrainosus. One hundred percent technical success was achieved with mean reduction of pain scores of 2.4, which was statistically significant (P &lt; 0.0001). There were no immediate or acute complications. LIMITATIONS: Results of this study were based on retrospective study. The use of VAS may be subjective, and the need of a prospective study may be necessary. CONCLUSIONS: With 100% technical success, statistically significant pain reduction, and no complications, we support SPG block in the pediatric population as a simple, efficacious, and safe treatment option for refractory headaches. It is routinely performed in less than 10 minutes and commonly negates the need for inpatient headache pain management. Given its minimal invasivity, we support the use of SPG blockade as a therapeutic treatment in refractory pediatric migraines as it reduces the need for intravenous medications, prolonged pain control, or hospital admission. KEY WORDS: Chronic, migraine, minimally invasive, nerve block, pediatric, sphenopalatine

Difficult to Treat (Refractory) Chronic Migraine: Outpatient Approaches

This comprehensive review addresses the many challenges in treating refractory migraine. Issues relating to pathophysiology are covered. A unique “refractory scale for migraine patients” is introduced. The definition and role of medication overuse headache are presented with a much different perspective than is usually found. Issues outside of medication that are covered include active coping, acceptance, resilience, and catastrophizing. A number of outpatient treatments are thoroughly discussed. These include the role of onabotulinum toxin, the application of polypharmacy, when to employ sphenopalatine ganglion blocks, the role of occipital and trigger-point injections, the implementation of long-acting opioids, the advantages of stimulants, and the possible use of monoamine oxidase inhibitors. Miscellaneous approaches include muscle relaxants, nasal or intravenous ketamine, transcranial magnetic stimulation, memantine, and ergonovine. Finally, many cutting-edge “refractory clinical pearls” are listed. This review contains 8 highly rendered figures, 4 tables, and 25 references. Key Words: Headache, migraine, chronic, refractory, medication overuse, alternative, treatments

Difficult to Treat (Refractory) Chronic Migraine: Outpatient Approaches

This comprehensive review addresses the many challenges in treating refractory migraine. Issues relating to pathophysiology are covered. A unique “refractory scale for migraine patients” is introduced. The definition and role of medication overuse headache are presented with a much different perspective than is usually found. Issues outside of medication that are covered include active coping, acceptance, resilience, and catastrophizing. A number of outpatient treatments are thoroughly discussed. These include the role of onabotulinum toxin, the application of polypharmacy, when to employ sphenopalatine ganglion blocks, the role of occipital and trigger-point injections, the implementation of long-acting opioids, the advantages of stimulants, and the possible use of monoamine oxidase inhibitors. Miscellaneous approaches include muscle relaxants, nasal or intravenous ketamine, transcranial magnetic stimulation, memantine, and ergonovine. Finally, many cutting-edge “refractory clinical pearls” are listed. This review contains 8 highly rendered figures, 4 tables, and 25 references. Key Words: Headache, migraine, chronic, refractory, medication overuse, alternative, treatments

Difficult to Treat (Refractory) Chronic Migraine: Outpatient Approaches

This comprehensive review addresses the many challenges in treating refractory migraine. Issues relating to pathophysiology are covered. A unique “refractory scale for migraine patients” is introduced. The definition and role of medication overuse headache are presented with a much different perspective than is usually found. Issues outside of medication that are covered include active coping, acceptance, resilience, and catastrophizing. A number of outpatient treatments are thoroughly discussed. These include the role of onabotulinum toxin, the application of polypharmacy, when to employ sphenopalatine ganglion blocks, the role of occipital and trigger-point injections, the implementation of long-acting opioids, the advantages of stimulants, and the possible use of monoamine oxidase inhibitors. Miscellaneous approaches include muscle relaxants, nasal or intravenous ketamine, transcranial magnetic stimulation, memantine, and ergonovine. Finally, many cutting-edge “refractory clinical pearls” are listed. This review contains 8 highly rendered figures, 4 tables, and 25 references. Key Words: Headache, migraine, chronic, refractory, medication overuse, alternative, treatments

Difficult to Treat (Refractory) Chronic Migraine: Outpatient Approaches

This comprehensive review addresses the many challenges in treating refractory migraine. Issues relating to pathophysiology are covered. A unique “refractory scale for migraine patients” is introduced. The definition and role of medication overuse headache are presented with a much different perspective than is usually found. Issues outside of medication that are covered include active coping, acceptance, resilience, and catastrophizing. A number of outpatient treatments are thoroughly discussed. These include the role of onabotulinum toxin, the application of polypharmacy, when to employ sphenopalatine ganglion blocks, the role of occipital and trigger-point injections, the implementation of long-acting opioids, the advantages of stimulants, and the possible use of monoamine oxidase inhibitors. Miscellaneous approaches include muscle relaxants, nasal or intravenous ketamine, transcranial magnetic stimulation, memantine, and ergonovine. Finally, many cutting-edge “refractory clinical pearls” are listed. This review contains 8 highly rendered figures, 4 tables, and 25 references. Key Words: Headache, migraine, chronic, refractory, medication overuse, alternative, treatments

Difficult to Treat (Refractory) Chronic Migraine: Outpatient Approaches

This comprehensive review addresses the many challenges in treating refractory migraine. Issues relating to pathophysiology are covered. A unique “refractory scale for migraine patients” is introduced. The definition and role of medication overuse headache are presented with a much different perspective than is usually found. Issues outside of medication that are covered include active coping, acceptance, resilience, and catastrophizing. A number of outpatient treatments are thoroughly discussed. These include the role of onabotulinum toxin, the application of polypharmacy, when to employ sphenopalatine ganglion blocks, the role of occipital and trigger-point injections, the implementation of long-acting opioids, the advantages of stimulants, and the possible use of monoamine oxidase inhibitors. Miscellaneous approaches include muscle relaxants, nasal or intravenous ketamine, transcranial magnetic stimulation, memantine, and ergonovine. Finally, many cutting-edge “refractory clinical pearls” are listed. This review contains 8 highly rendered figures, 4 tables, and 25 references. Key Words: Headache, migraine, chronic, refractory, medication overuse, alternative, treatments

Considerations for Epidural Blood Patch and Other Postdural Puncture Headache Treatments in Patients with COVID-19

Background: A primary concern in the use of EBP in these patients is the possibility of seeding the virus in the CNS. Another important concern is related to the known hypercoagulable state in COVID-19 positive patients and associated organ dysfunction that may alter the metabolism of anticoagulants. The safety of the providers performing the EBP, the position of the patient and choices for image guidance (blind, fluoroscopic) are also key considerations to review. It is also important to explore the current state of knowledge about using allogenic instead of autologous blood as well as emerging techniques to eliminate the coronavirus from the blood. Objectives: In this article we pose the questions of how to manage PDPH in the COVID-19 positive patient and more specifically, the use of epidural blood patch (EBP). Methods: Literature review. Results: EBP is usually considered after the failure of conservative and pharmacological treatments. Because of the additional risks of EBP in COVID-19 patients it is important to also consider less traditional pharmacological treatments such as theophylinnes and cosyntropin that may offer some additional benefit for COVID-19 patient. Finally, other interventions other than EBP should also be considered including occipital nerve blocks, sphenopalatine ganglion blocks (infratemporal or transnasal). Limitations: A narrative review with paucity of literature. Conclusion: Going forward, an effective treatment for COVID-19 or a safe vaccine and a deeper understanding of the pathophysiology of the virus will certainly change the risk calculus involved in performing an EBP in a COVID-19 patient. Key words: COVID-19; PDPH; Epidural Blood Patch; Post-dural Puncture Headache

Cortical and subcortical changes following sphenopalatine ganglion blocks in chronic migraine with medication overuse headache: a preliminary longitudinal study

ObjectiveThe purpose of this pilot study was to investigate potential changes in brain morphology (cortical thickness and cortical/subcortical volume) accompanying a series of sphenopalatine ganglion (SPG) blockade treatments in chronic migraine with medication overuse headaches (CMw/MOH).BackgroundLocal anesthetization of the SPG via intranasal application is used for the treatment for multiple types of headache disorders, including CM. Our previous longitudinal fMRI study revealed improved network connectivity after such treatment. However, the impact of SPG blocks on cortical, subcortical gray matter volume and cortical thickness has yet to be assessed.MethodsUsing magnetic resonance imaging (MRI), cortical/subcortical volume were measured in 12 chronic migraine patients before and after a series of 12 SPG blocks administered over a 6-week period (2 per week). The average time between MRI assessments was 6 weeks. Targeted, within-subjects t-tests comparing pre-treatment and post-treatment values in specific apriori brain regions of interest, including the hippocampus, amygdala, basal ganglia, somatosensory cortex, temporal cortex and occipital cortex, were used to estimate the impact of repetitive SPG blocks treatment on brain morphology in CMw/MOH.ResultsCompared to baseline values, the number of moderate/severe headache days per month, HIT-6, PHQ-9 scores and allodynia scores were all significantly improved at the end of treatment. Analysis of MRI data revealed that the volume of the right hippocampus and the right palladium significantly decreased following SPG block treatment, while the volume of the left nucleus accumbens significantly increased following treatment. Cortical thickness in the left temporal pole and left lateral occipito-temporal gyrus significantly decreased following SPG block treatment.ConclusionOur results suggest SPG block treatment is associated with significant symptom improvement as well as significant structural brain changes in regions known to be associated with migraine and chronic pain processing in CMw/MOH.