Trigeminal Neuralgia: First Line Approach with SPG Blocks Can Be Safe and Effective

Trigeminal Neuralgia (TN) has been called the Suicide Disease. The medical community typically considers  carbamazepine and oxcarbazepine as First Line Treatment.   I suggest that for many patients Sphenopalatine Ganglion Blocks are a far safer and offer a far more effective first line approach to addressing Trigeminal Neuralgia (TN) without a multitude of medication side effects.  Side effects of Carbamazepine (Tegretol) and oxcarbazepine (Trileptal) include:

  • nausea,
  • vomiting,
  • dizziness, lightheadedness or fainting
  • drowsiness,
  • dry mouth,
  • swollen tongue,
  • loss of balance or coordination.
  • unsteadiness.
  • Headache
  • Mental Slowness
  • Trouble Concentrating and/or memory problems.
  • Trouble Sleeping
  • Shaing
  • Acne
  • Constipation
  • Trouble Walking
  • Changes in Vision
  • Uncontrolled muscle movements
  • Chest Pain
  • Bleeding or Bruising
  • Stomach Pain
  • Changes in vision
  • Bloody Stool
  • Dark urine or change in volume of urine

Trigeminal neuralgia is probably the most painful chronic pain known and it affects the trigeminal nerve, which carries sensation from your face to your brain. Trigeminal neuralgia, even slight touch or wind on your face or activities like brushing your teeth or putting on makeup can trigger a jolt of excruciating pain.

TN sufferers may experience short, mild attacks initially but it can progress causing longer and more-frequent bouts of searing, shooting or burning pain. TN affects women more often than men, and it occurs more frequently in people who are older than 50.

Because of the variety of treatment options available, having trigeminal neuralgia doesn’t necessarily mean you’re doomed to a life of pain. Doctors usually can effectively manage trigeminal neuralgia with medications, injections or surgery.

There are a wide variety of treatments for Trigeminal Neuralgia. One of the least invasive and frequently successful alternatives treatments is Sphenopalatine Ganglion Blocks (SPG Blocks) also called Pterygopalatine Ganglion Blocks or Nasal Ganglion Blocks.  Neuromuscular Dentistry can also be extremely successful due in part to the use of the Myomonitor.  The Myomonitor is an ULF-TENS that acts to stimulate both the facial and trigeminal nerves and the Sphenopalatine Ganglion that its on the maxillary division of the trigeminal nerve.  The Myomonitor has over a 50 year safety record in treating Trigeminal Neuralgia and TMJ disorders.

The best method of delivering SPG Blocks is with a cotton tipped nasal catheter, and I will explain further after discussing more common methods. Trigeminal Neuralgia patients especially seem to respond well to the use of cotton tipped nasal catheters.

SPG Blocks can be administered in multiple ways. There are multiple methods of Injection both intraoral and extraoral. They can be done with or without fluoroscopy though it is rarely needed can offer, The Suprazygomatic injection is the most reliable in my practice.

There are also multiple means of delivering Sphenopalatine Ganglion Blocks with nasal Catheters. There are three commercial brands of nasal catheters specifically designed for SPG Blocks.

The Sphenocath nasal is what I utilize in my office for a patients who are not good candidates for the cotton tipped nasal catheter. The Allevio is similar to the Sphenocath as well. The third type is the TX360. It is the device utilized for the MiRX protocol. All three devices are basically squirt guns that shoot anesthetic over the mucosa covering the Shenopalatine Ganglion.

I feel that the cotton tipped nasal catheters are by far the best delivery method for multiple reasons.

1. The supply a continuous capillary feed of anesthetic to the mucosa over the ganglion. Even if an exact location is missed the continuous feed guarantees that the anesthetic flows to the proper area.

2. They are relatively easy for patients to self administer. Frequency of doing the Block is key to the highest success. I generally have patients due the blocks twice a day initially until the pain is well controlled.

3. Convenience of a self administered block avoids trips to the physician or ER, travel, wait times etc.

4. Cost is a major factor. All other methods are very expensive running from $700 to thousands of dollars per application. Self-administered after initial appointment is approximately$1.00 per bilateral application.

5. Highest Success due to more frequent use secondary to low cost and convenience

This is a video of a recent patient who had multiple brain surgeries withou relief who then had a sphenopalatine ganglion block:

 

Side effects of SPG Blocks:

  1.  most common is slight nasal irritation
  2. reduction of high blood pressure
  3. reduced sympathetic activity
  4.  reduced anxiety
  5. self of well being or calm
  6. Beneficial body effects of lidocaine

What is New again is often very old as this text about a 1925 medical article shows: https://jamanetwork.com/journals/jamaotolaryngology/article-abstract/539798

SPG Blocks: Patient Stories and Testimonials:

https://www.youtube.com/channel/UCk9Bfz6pklC7_UluWFHzLrg/videos

Neuromuscular Dntistry also has been shown to calm down the Trigeminal Nervous system.  The ULF TENS or Myomonitor is a safe and effective stimulator of the Sphenopalatine Ganglion that is primarily designed to relax masticatory muscles.  Reduction of excessive input to the trigeminal system with the myomonitor also decreases irritability of trigeminal nerves.

I advise that no one considers the following  Neurolytic Agent treatments unless they first try regular administration of twice daily self-administered SPG Blocks.

Neurolytic agents may provide a longer duration of pain relief by causing destruction of nerve fibers and wallerian degeneration of axonal fibers and Schwann cells. The neurons regenerate in 3-5 months.  1-2 weeks may be required before complete pain relief is experienced.

Neurolytic agents used in trigeminal nerve blocks:

  • Glycerol (100%) – This agent is frequently utilized for treating trigeminal neuralgia; it is a mild neurolytic agent, but it can  cause perineural damage.
  • Alcohol (50-70%) –This has a high rate of complications; it can seep into surrounding tissues and cause necrosis and permanentcellular injury, and it can also cause vasospasm.  I do not Recomend it’s use.
  • Phenol (4-10%) – This agent is also commonly used; it can cause warmth and numbness on injection. It can cause convulsions and cardiovascular collapse if inadvertently injected intravascularly (into blood vessels)

Relevant Links:

Trigeminal Neuralgia: Sphenopalatine Ganglion Block Treatment

Sphenopalatine Ganglion Blocks for Trigeminal Neuralgia and RSD

https://clinicaltrials.gov/ct2/show/NCT01761604

Sphenopalatine Ganglion Block

https://paindoctor.com/treatments/sphenopalatine-ganglion-block/

PUBMED ABSTRACTS:

Curr Pain Headache Rep. 2017 Jun;21(6):27. doi: 10.1007/s11916-017-0626-8.

Sphenopalatine Ganglion Block in the Management of Chronic Headaches.

Mojica J1, Mo B1, Ng A2.

Author information

Abstract

PURPOSE OF REVIEW:

Sphenopalatine ganglion (SPG) block has been used by clinicians in the treatment of a variety of headache disorders, facial pain syndromes, and other facial neuralgias. The sensory and autonomic fibers that travel through the SPG provided the scientific rationale for symptoms associated with these head and neck syndromes. Yet, despite the elucidation of this pathogenic target, the optimal method to block its pain-producing properties has not been determined. Clinicians have developed various invasive and non-invasive techniques, each of which has shown variable rates of success. We examined the available studies of sphenopalatine ganglion blockade and its efficacy in the treatment of cluster headaches, migraines, and other trigeminal autonomic cephalalgias.

RECENT FINDINGS:

Studies have demonstrated that SPG blockade and neurostimulation can provide pain relief in patients with cluster headaches, migraines, and other trigeminal autonomic cephalalgias. Patients with these conditions showed varying levels and duration of pain relief from SPG blockade. The efficacy of SPG blockade could be related to the different techniques targeting the SPG and choice of therapeutic agents. Based on current studies, SPG blockade is a safe and effective treatment for chronic headaches such as cluster headaches, migraines, and other trigeminal autonomic cephalalgias. Future studies are warranted to define the optimal image-guided technique and choice of pharmacologic agents for SPG blockade as an effective treatment for chronic headaches related to activation of the sphenopalatine ganglion.

KEYWORDS:

Cluster headache; Hemicrania continua; Migraine headache; Paroxysmal hemicrania; Sphenopalatine ganglion block; Trigeminal autonomic cephalalgias

PMID:
28432602
DOI:
10.1007/s11916-017-0626-8

PUBMED Abstracts:

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.

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 SPGsensory 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.

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.

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