What is the best method of delivering a SPG Block? There are many alternatives for delivering SPG Blocks, I personally feel that self-administration is the best approach for the majority of patients. I utilize a wide variety of methods in some circumstances. Is Lidocaine the drug of choice for Cluster Headaches? The answer is yes for many if not most patients but the method of delivering the lidocaine is important.
An excellent new article “Sphenopalatine Ganglion Block (SPG) in the Management of Chronic Headaches” in Current Pain and Headache Reports by Jeffery Mojica, Bi Mo & Andrew Ng does an excellent job in discussing both pathogenesis and treatment of Cluster Headaches utilizing Sphenopalatine Ganglion Blocks.
This article will discuss only that portion of their article dealing with Cluster Headaches but the article concluded in part that “, SPG blockade is a safe and effective treatment for chronic headaches such as cluster headaches, migraines, and other trigeminal autonomic cephalalgias”
Cluster Headache is one of the Trigeminal Autonomic Cephalgias. According to the article “The autonomic symptoms of the various forms of headaches mimic the activation of the SPG. Therefore, the SPG has become a therapeutic target of interest. Symptoms such as lacrimation, conjunctival injection, nasal congestion, rhinorrhea, forehead sweating, and periorbital edema are common autonomic manifestations of trigeminal autonomic cephalalgias (TACs). The presence of these symptoms suggests that SPG may be a key structure in their pathogenesis.”
TACs include cluster headache (CH), paroxysmal hemicranias (PH), short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT), Long-lasting autonomic symptoms with hemicrania (LASH), Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA)and hemicrania continua (HC).
“Cluster headache is the most common type of TACs. CH is characterized by unilateral headaches in Maxillary Division of the Trigeminal Nerve distribution that are classically associated with parasympathetic disruption, causing lacrimation, conjunctival injection, nasal congestion, and rhinorrhea.”
The Sphenopalatine Ganglion has a very long history in the treatment of chronic headaches, migraines and Cluster headaches. It was originally described by Greenfield Sluder in 1903 in case now thought to be a cluster headache. The Sphenopalatine Ganglion (SPG) has many names including Sluder’s Ganglion, the Nasal Ganglion, the Pteryggoalatine Ganglion named for its location in the Pteryggopalatine fossa, anr Meckel’s Ganglion.
The Sphenopalatine Ganglion is the largest parasympathetic ganglion of the head and in addition to parasympathetic fibers it also carries somatosensory fibers and sympathetic fibers. According to the article “The sphenopalatine ganglion is activated when the superior salivatory nucleus receives stimulation from the trigeminal afferent nerves. This results in parasympathetic activation of the meningeal vessels, lacrimal glands, nasal, and pharyngeal mucosa. This signaling pathway is referred to as trigeminal-autonomic reflex.” The Vascular and Neurogenic type headache pain is secondary to the release of vasoactive peptides.
This review cited five studies on SPG Blocks for Cluster Headache. The first by Devoghel looked at 120 patients treated with Sphenopalatine Blocks by Supra-Zygomatic injection. 103 (94%) experienced complete relief and 17 reported no relief.
The second study looked at was by Barre of 11 Cluster headache patients treated with Intranasal cotton-tipped application of cocaine or lidocaine. All of the patients in this smaller study reported a minimum of than reduction in headache intensity. This study utilized the same technique originally described by Sluder in 1903.
The third study was by Kittrelle et al. was small with only 5 patients and utilized 4% lidocaine delivered by intranasal droplet. 4 of the 5 patients experienced a 75% decrease in headache intensity.
The fourth study by Robbins looked at 30 patients where 4% lidocaine was deliered by intranasal spray and 16 or slightly more than half experienced mild to moderate relief. 14 of the patients experienced no relief.
The last study by Costa et al.was a double-blind, placebo-controlled study with rhinoscopic-guided bilateral intranasal cotton-tipped application of 10% cocaine or 10% lidocaine. All patients reported complete relief with application of both lidocaine and cocaine. This technique again utilized Sluder’s original application technique.
There are three newer FDA approved catheter devices for delivering Sphenopalatine Ganglion blocks as well.
There is no question about the effectiveness of of Sphenopalatine Ganglion Block in the treatment of Cluster Headache. What is amazing is that the Sphenopalatine Ganglion had become what is called “Forgotten Medicine” Many excellent techniques get “lost” when newer techniques come along. The era of polypharmacy approach to headaches has been over 50 years in the making. Research and research money is spent looking for the “Magic Cure” or “magic pill” to treat specific issues and doctors are never trained in old techniques.
The SPG Block is a perfect example of “Forgotten Medicine” This is a video of a physician who had a severe disabling headache as a young boy and was treated with an SPG Block. This boy decided to become a physician because of this experience, he wanted to help others as he had been helped. Unfortunately, he was never taught or learned about SPG Blocks and after 10 years in practice he quit because he was unable to help patients in the manner he was helped. He became an artist and makes magnificent trees. This video was taken the day he learned what a SPG Block actually was.
The history of SPG Blocks began with Greenfield Sluder in 1903. He published many articles on these blocks and wrote two books. The first in 1918″Concerning Some Headaches and Eye Disorders of Nasal Origin” and the second “Nasal Neurology, Headaches and Eye Disorders” while he was a clinical professor and Director of the Department of Oto-Laryngology at Washington University School of medicine in St Louis.
There was a great deal of interest in these blocks and in 1930 Hiram Byrd MD and Wallace Byrd AB. wrote a paper published in the Annals of Internal Medicine (JAMA) on Phenopalatine Phenomena” that looked at 10,000 blocks in over 2000 patients.
This amazing block almost disappeared but in 1986 a book was published “Miracles on Park Avenue” by Albert Gerber about the medical practice of Milton Reder MD a world-famous New York City Otolarymgologist whose entire practice was utilizing SPG Blocks to treat a wide variety of chronic pain disorders with extreme success in thousands of patients including senators, generals, magnates, kings, Hollywood and Broadway stars and many prominent medical practitioners. Dr Reder and this book written about this “Miracle Block” probably saved this treatment from the dustbin of obscurity.
I originally learned the technique in 1986 when a patient gave me a copy of the book and asked me to find someone in Chicago who used this technique. I read this book in one sitting and found there was no one using it. I finally found a colleague in the TMJ field in Kansas City who knew the technique, Dr Jack Haden and learned it from him.
I have been using this remarkable block since 1986. Initially, I used a 10% cocaine solution but later switched to 4% and the 2% lidocaine. I used the same technique as both Sluder, Byrd and Reder but later switched to a cotton-tipped catheter that allowed continuous capillary release of anesthetic.
Looking at these studies you will see that they use either lidocaine or cocaine and both are effective. The applicator is more effective than drops which are more effective than the sprays of lidocaine. Devoghel used an injection technique utilizing alcohol which is longer lasting than lidocaine or cocaine but carries more risk. This was described by both Sluder and Byrd in their publications.
I believe the best approach is to teach patients to self-administer SPG Blocks with cotton tipped nasal catheters that continually provide anesthetic to the mucosa over the ganglion. Some nasal passages are difficult to negotiate. There are three new devices made to deliver SPG Blocks, they are the Sphenocath, the Allevio and the TX 360. They are all nasal catheters used like “squirt guns” They care all more effective than lidocaine spray or drops. They are relatively expensive devices, $75.00 for a single use. Physicians typically charge $750.00 per bilateral block.
I teach patients to Self-Administer SPG Blocks with cotton-tipped applicators but for some difficult access noses I teach patients to self-administer with a Sphenocath device which can be reused by a patient. Patients can also self-administer with the TX 360 but it is strictly a single use device.
The use of Afrin (oxymetazoline ) spray can shrink mucosal membranes making self administration easier and I supply patients with spray bottles for lidocaine so they can numb nasal mucosa prior to self administration of SPG Block.
The advantage to self-administration is it is available to the patient on an as needed basis. This allows the patients to avoid repeated trips to the ER or physician offices.
SPG Blocks can also be utilized to treat other pain disorders like Fibromyalgia. This video is a disabled Israeli veteran who suffered for nine years from Fibromyalgia before trying SPG Block.
A new article in World Neurology in October 2018 looked at the efficacy of Sphenopalatine Ganglion Radiofrequency surgery in refractory chronic cluster headaches and concluded “Radiofrequency of the SPG is a safe, fast, and partially effective method for the treatment of CCHr. Given its low rate of complications and its low economic cost, we think it should be one of the first invasive treatment options, prior to techniques with greater morbidity and mortality, such as neuromodulation.”
Comparing Radiofrequency surgery of the sphenopalatine Ganglion to Self-Administered SPG Blocks with trans-nasal catheters on could conclude “Self-Administered SPG Blocks is a safe, fast, and effective method for the treatment of CCHr. Given its low rate of complications and its low economic cost, we think it should be considered as an alternative to invasive treatment options due to low morbidty, low cost and effectiveness.”
An excellent article in Neurotherapeutics April 2018 on Therapeutic approaches for the management of Trigeminal Autonomic Cephalgias is an excellent resource and is available in a free full text version at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5935647/
It is amazing as one reads the article and considers the Myomonitor a ULF-TENS with a 50 year safety record actually can accomplish much of what this new technology does including neuromodulation of Sphenopalatine Ganglion, Facial Nerve, Trigeminal nerve, Vagus nerve, occipital nerve, greater and lesser occipital nerves as well as muscular targets. In neuromuscular dentistry it is used in conjunction with diagnostic neuromuscular orthotics to not only treat but to correct underlying conditions responsible for headaches.
It is frequently used in conjunction with Sphenopalatine Ganglion Blocks .