Sphenopalatine Ganglion Blocks are indicated for a wide of conditions including chronic daily headaches, chronic migraines, cluster headaches, Tension-Type Headache, TMJ disorders, Trigeminal Neuralgia, Myofascial Pain, Trigeminal Neuralgia, chronic rhinitis and many other conditions.
There are many ways to deliver Sphenopalatine Ganglion (SPG) blocks by injection and transnasal approaches.
The original description of Sphenopalatine (pterygopalatine) ganglion blocks by Sluder in 1903 was a transnasal approach using a cocaine soaked pledget on a small wire. This was the same approach utilized by Dr Milton Reder as described in the book “Miracles on Park Avenue”.
Over time cotton tipped applicators used with different local anesthetics (or cocaine) came into more common use. The SPG Block procedure, once a mainstay of treatment fell to the side as pharmaceutical companies vastly expanded the number of medications available to treat these condition and many (if not most) physicians were not trained in doing Sphenopalatine Ganglion Blocks.
This video is a physician who specifically went into medicine due to his personal experience with instantaneous relief with an SPG Block of severe headache pain as a young boy. After completing medical school he went into practice and tried to reproduce the results in his patients that he had achieved with treating pain. Unfortunately he was never taught the procedure and though he tried he could not reproduce the results he expected. He left medicine and became an artist partially due to not being able to drastically improve his patient’s state of being. The video was taken the day he found out what a SPG Block was for the first time. https://www.youtube.com/watch?v=Sn46l_nH9-A
In the last few years three companies have produced FDA Approved commercial devices for administering Sphenopalatine Ganglion Blocks. Several studies have shown that repetitive SPG Blocks can relieve headaches and migraines and reduce the frequency of new attacks.
There are currently three devices on the market specifically designed for SPG Blocks:
The Sphenocath which is designed with a small soft tube specifically designed to be inserted into a patient’s nose as they lie on their back and deliver medications precisely and consistently to the area of the sphenopalatine ganglion.
The Allevio is very similar to the Sphenocath Device. Both the Sphenocath device and the Allevio are designed to be attached to a standard Luer Lock syringe to deliver anesthetics to a supine (on back) patient.
The TX 360 by Tian Medical also connects with a Luer Lock syringe and has two barrels designed to direct a small flexible catheter to the mucosa area directly over the sphenopalatine ganglion. It is the device used for the MiRx protocol.
All three of these devices can deposit anesthetic directly over the mucosa covering the area of the Sphenopalatine Ganglion. They all require that the patient be in a supine position ideally for 10-20 minutes after placement.
I believe the best technique is the Cotton Tipped Nasal Catheters that I utilize but there is an interesting article about a another technique that was described by Robert E. Windsor, MD, and Scott Jahnke, DO in their article “Sphenopalatine Ganglion Blockade: A Review and Proposed Modification of the Transnasal Technique” in Pain Physician. 2004;7:283-286, ISSN 1533-3159. I am including their bibliography at the end of this post.
You can read the entire articles at:
https://pdfs.semanticscholar.org/a544/7aa577a66a21bf6f278cdabaf66d785035d0.pdf
The best technique, in my opinion is the one I utilize which uses a cotton tipped nasal catheter that provides continuous capillary feed of anesthetic to the mucosa over the ganglion. It has numerous advantages including delivering anesthetic continuously over longer periods of time and allows the patient freedom to watch TV, read a book, walk around or use computer of table while it delivers additional anesthetic by capillary action.
Most important is that patients can easily self administer SPG blocks as often as needed to completely control the symptoms. I have taught patients to self administer with the Sphenocath device in the past. The Sphenocath is designed for a single usage but can be reused by a patient for self-administration of SPG Blocks.
There is a new product on the horizon the Relaspen Potable Migraine Blocker.
It is an improvement over nasal spray administration of lidocaine because it focusses the delivery with small flexible catheters directly over the mucosa over the medial wall of the Pterygopalatine Fossa. It is intended for emergency use for acute migraine occurrences. I frequently have patients utilize lidocaine spray to increase comfort of inserting the Cotton-Tipped nasal catheters that offer continual capillary feed.
Relapsen Portable Migraine Blocker is a small portable way to deliver lidocaine quickly and comfortably to the SPG. It has the same problems as other nasal delivery systems but is easier and more comfortable application. While Relaspen may be less effective that sphenocath or TX360 it is portable and ideal for emergency treatment during the day when acute migraines occur. The Relaspen device has a smaller flexible catheter that will give less precise delivery of anaesthetic but ufficient for fast relief.
The TX 360 can also be utilized for self-administration but it is single use only.
The cost to self deliver a block with the cotton-tipped catheters is under $1.00 per bilateral block compared to $75.00 for for the TX 360 device for self administration.
Self-administration with cotton-tipped catheters with continual capillary feed is very patient friendly and they can be bent according to the protocol of Hiram Byrd in his 1930 paper “Sphenopalatine Phenomena: Present State of Knowledge”. Self-administration with cotton-tipped catheters will continue to be the Gold Standard of treatment in the opinion of this author.
Patient’s controlling the frequency of blocks from twice daily to bi-weekly or monthly puts them in control of there pain symptoms. I frequently have patients doing self-administration to start with twice daily application to rapidly reduce symptoms and then slowly decrease frequency of application. This is feasible because it does not involve trips to physician offices or emergency departments.
This link is to patient and Dr Testimonials about SPG Blocks. You can fast forward to skip specific videos.
The following is the Bibliography from Robert E. Windsor, MD, and Scott Jahnke, DO
REFERENCES 1. Sluder G. The anatomical and clinical relations of the sphenopalatine ganglion to the nose. NY State J Med 1909; 90:293- 298. 2. Sluder G. Nasal Neurology, Headaches and Eye Disorders. St. Louis, CV Mosby, 1927. 3. Ruskin A. Sphenopalatine (nasal) ganglion: Remote effects including “psychosomatic” symptoms, rage reaction, pain, and spasm. Arch Phys Med Rehabil 1979; 60: 353-359. 4. Procacci P, Francini F, Zoppi M et al. Cutaneous pain threshold changes after sympathetic block for reflex dystrophies. Pain 1975; 1:167-175. 5. Reder M, Hymanson A, Reder M. Sphenopalatine ganglion block in treatment of acute and chronic pain. In Hendler NH, Lond DM, Wise TN (eds.) Diagnosis and Treatment of Chronic Pain. Boston, John Wright, 1982, pp 97-109. 6. Barre F. Cocaine as an abortive agent in cluster headaches. Headaches 1982; 22: 69-73. 7. Kittrelle J, Grouse D, Seybold M. Local anesthetic abortive agents. Arch Neurol 1985; 42:496-498. 8. Berger J, Pyles ST, Saga-Rumly S: Does topical anesthesia of the sphenopalatine ganglion with cocaine or lidocaine relieve low back pain. Anesth Analg 1986; 65: 700-702. 9. Raj P, Lou L, Erdine S et al. Radiographic imaging for regional anesthesia and pain management. New York, Churchill Livingstone, 2003, pp 66-71. 10. Waldman S. Atlas of Interventional Pain Management. Philadelphia, WB Sanders, 1998, pp 10-12. 11. Edvinsson L. Innervation and effects of dilatory neuropeptides on cerebral vessels. Blood Vessels 1991; 28:35-45. 12. Reder M, Hymanson A, Reder M. Sphenopalatine ganglion block in treatment of acute and chronic pain. In Hendler N, Lond D, Wise T (eds). Diagnosis and Treatment of Chronic Pain. Boston, John Wright, 1982, pp 97-109. 13. Waldman S. Sphenopalatine ganglion block- 80 years later. Reg Anesth 1993; 18:274-276. 14. Salar G, Ori C, Iob I. Percutaneous thermocoagulation for sphenopalatine ganglion neuralgia. Acta Neurochir (Wien) 1987; 84:24-28. 15. Waxman S: Correlative Neuroanatomy, 23rd ed. Stamford, Appleton & Lange, 1996, pp 265-266. 16. Hardebo J, Arbab M, Suzuki N et al. Pathways of parasympathetic and sensory cerebrovascular nerves in monkeys. Stroke 1991; 22:331-342. 17. Eagle W. Sphenopalatine neuralgia. Acta Otolaryngol 1942; 35:66-84. 18. Gardner G, Gray A, O’Rahilly S: Anatomy: A Regional Study of Human Structure, 5th ed. Philadelphia, WB Sanders, 1906, pp 676-677. 19. Windsor R, Gore H, Merson M: Interventional sympathetic blockade. In Lennard T (ed.) Pain Procedures in Clinical Practice, 2nd ed. Philadelphia, Hanley & Belfus, 2000, pp 321-324.