SPG Block

The Sphenopalatine Ganglion and Headaches

The SPG Block

What is an SPG Block (Sphenopalatine Ganglion Block) and why should I consider it for my patient?

The sphenopalatine ganglion block / sphenopalatine ganglion (SPG) is located just deep to the nasal mucosa posterior to the middle nasal turbinate. The SPG can be blocked by diffusion of local anesthetic through the overlying mucosa. Sensory, sympathetic and parasympathetic fibers pass through or synapse in the SPG, making it a key structure in various types of cephalgia. Temporarily blocking function of the SPG can provide prompt, and sometimes sustained, relief of pain. It is theorized that SPGB provides sustained relief by disrupting dysfunctional neuronal activity, allowing restoration of normal function.

Getting serious about blocking headache pain.

Currently there is very little to offer the chronic migraine headache patient. Nearly two thirds of patients discontinue prescription medications due to inadequate relief and side-effects.

SPG blocks achieve neuromodulation of the sphenopalatine ganglion complex. This means that the time-tested efficacy of the procedure has been shown to have both immediate and sustained results. These effects are typically sustained by interrupting the chaotic signaling associated with migraine.

Although proven effective, few physicians offer the SPG block to patients because the traditional procedures are uncomfortable and dangerous for the patient and demanding for the care giver. Traditionally, the block is attempted by navigating a cotton tip applicator through the nasal passages and place it there for 30 minutes, or with a long needle through the side of the head. These approaches carry risks and sometimes require sedation.

Today, establishing an SPG block has never been easier. The patented Tx360EU offers the practitioner the ability to offer a first-line treatment in the chronic headache patient. Tx360EU delivers medication that can sustain pain relief in a ten to thirty seconds procedure that is comfortable and quick. With Tx360EU, SPG may be achieved without needles, cotton swabs, atomizer sprays or systemic narcotics.

SPG blocks have time-tested efficacy when it comes to serious chronic and episodic migrainous pain.

SPG Blocks have been performed for centuries, but new technology allows them to be performed with comfort and ease

Sphenopalatine Ganglion Block Migraine Treatment
Sphenopalatine ganglion block

Tx360® is a single-use, disposable catheter that delivers medication through the nasal passages to a difficult-to-reach ganglion located at the back of the nose easily, safely, efficiently and accurately (only 0.6cc of medication needed).

When used as indicated, Tx360® delivers the medication immediately proximate to the ganglion to achieve a Sphenopalatine Ganglion or SPG block. Interventional radiologists, neurologists, internists, emergency departments and pain specialists are interested in utilizing Tx360® for a safe, comfortable and quick delivery of the medication required for the SPG block procedure.

This drug delivery innovation, is drawing the attention of physicians who treat patients with chronic and episodic migraine, cluster headache, and chronic daily headache and for other applications. The SPG blocks have been studied for many disorders for over a century. More recently however, the block has been associated with profound neuromodulation of the SPG complex, resetting the chaotic signaling associated with chronic migraine with both immediate and sustained results.

Though widely accepted as effective, few physicians are willing to perform an SPG block because the traditional procedures are uncomfortable for the patient and demanding for the caregiver. Formerly, the block was attempted by navigating a cotton tip applicator through the nasal passages, by atomizing a spray or with a long needle through the side of the head. These older approaches carry risks, sometimes require sedation and may not be effective in all patients.

Headache alone affects nearly 45 million individuals, and migraine occurs in 6.8% of men and 15-18% of women. Nearly two-thirds of headache patients discontinue prescription medications due to inadequate relief and side effects. The SPG block may also have utility in the treatment of other disorders. Tx360® is designed to deliver medicines right onto the sphenopalatine foreman in order to block the entire SPG apparatus. Tx360® allows easy and accurate placement of medications right onto the sphenopalatine foramen, no imaging guidance is necessary

Video Tutorial

Featuring Dr. Tian Xie, inventor of the Tx360®

Indications

For Migraine Headache:

Headaches at least 15 days per month for more than 3 months; have features of migraine headache on at least 8 days.

Features of migraine headache:

  • Lasts 4 to 72 hours;
  • Has at least 2 of the following 4 characteristics:
  • Unilateral
  • Pulsating
  • Moderate or severe pain intensity
  • Aggravates or causes avoidance of routine physical activity
  • Associated with:
    • Nausea and/or vomiting
    • Photophobia and phonophonia

(In ICHD-2, absence of medication overuse was one of the diagnostic criteria for chronic migraine. In the ICHD-3, this criterion was removed from the chronic migraine diagnosis and “medication overuse headache” is now a separate diagnostic category.)

For Cluster Headache:

Patient has had at least five attacks occurring from one every other day to eight per day; and attributable to no other disorder.

Headaches must cause severe or very severe unilateral orbital, supraorbital, or temporal pain lasting 15 to 180 minutes if untreated, and be accompanied by one or more of the following:  ipsilateral conjunctival injection or lacrimation, ipsilateral nasal congestion or rhinorrhea, ipsilateral eyelid edema, ipsilateral forehead and facial sweating, ipsilateral miosis or ptosis, or a sense of restlessness or agitation.

Episodic cluster headache is defined as at least two cluster periods lasting seven to 365 days and separated by pain-free remission periods of one month or longer. Chronic attacks recur over more than one year without remission or with remission lasting less than one month.

(Headache Classification Subcommittee of the International Headache Society.

The International Classification of Headache Disorders. 2d ed. Cephalalgia. 2004;

24(suppl 1):9–160.

For Medication-Overuse Headache

Patients with a pre-existing primary headache who, in association with medication overuse, develop a new type of headache or a significant worsening of their pre-existing headache (or one of its subtypes) should be given both this diagnosis and the diagnosis of the pre-existing headache.

Defined as headache occurring on 15 or more days/month in a patient with a pre-existing primary headache and developing as a consequence of regular overuse of acute or symptomatic headache medication (on 10 or more or 15 or more days/month, depending on the medication) for more than 3 months. It usually, but not invariably, resolves after the overuse is stopped.

Diagnostic criteria:

  • Headache occurring on ≥15 days/month in a patient with a pre-existing headache disorder
  • Regular overuse for >3 months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache
  • Not better accounted for by another ICHD-3 diagnosis.

(The International Headache Society third edition of the International Classification of Headache Disorders (ICHD-3). )

Contraindications:

  • Nasal or Sinus tumors
  • Nasal Foreign Body/Polyps
  • Sinusitis
  • Brain Tumor
  • Aneurysm
  • Anti-Viral Medication use
  • Post Radiation Therapy
  • Post Craniotomy Headache
  • Headaches due to Increased ICP * (?Topamax)
  • Post Trigeminal Nerve Decompression

Patient Selection:

  • Careful Selection Of Patients
  • Not For Occipital Neuralgia Or Cervicogenic Headaches
  • Not Effective For Drug Seekers
  • Less Effective For Patients With Severe Psychiatric Co-Morbidities
  • Ages 14 years old and above

Technique:

  • Check Blood Pressure Before SPGNB
  • Defer Block If Elevated BP Over 180/90
  • 10 To 30 Second Procedure
  • 25 TO 0.3 mL OF 0.5% MARCAINE TO EACH SPG
  • (BILATERAL)
  • Always Perform Bilateral Procedure.
  • Fast response.
  • Relief Last over 24 Hours
  • Repetitive Nerve Blocks for autonomic neuromodulation

Repetitive Blocks for Neuromodulation (protocol):

Treatment Frequency: 2-4 Injections Per Week For 3 to 6

Weeks Duration (up to 12 Total Injections)

FREQUENCY IS KEY TO NEUROMODULATION

Consider bilateral occipital nerve block

Once successfully treated initially, then 1 to 3 nerve block every 3 months.

Insurance

CPT Codes used for Procedure:   64505, Injection, anesthetic agent; sphenopalatine ganglion.

Procedure Note:  

Procedure performed for the purpose of controlling pain; to avoid or reduce the use of Opioids; to avoid or reduce ER visits.

Proper consent obtained, patient sitting, both pterygopalatine ganglion (branch of trigeminal nerve) anatomy and landmark identified and checked, Pre-Op VAS ?/10; Specialized device and its soft tip needle was used to inject 0.3cc of 0.5% sterile marcaine [or medication of choice] onto right sphenopalatine ganglion (branch of trigeminal nerve), same process repeated on the left side of spheopalatine ganglion (branch of trigeminal nerve).  Patient tolerated procedure well, no complications, EBL: none.  Post-Op VAS ?/10.  Patient discharged.

References

References

  • Aria Piagkou, Theano Demesticha, Theodore Troupis, Konstantinos Vlasis, Panayiotis Skandalakis, Aggeliki Makri, Antonios Mazarakis, Dimitrios Lappas, Giannoulis Piagkos, Elizabeth O Johnson. (2012) The Pterygopalatine Ganglion and its Role in Various Pain Syndromes: From Anatomy to Clinical Practice. Pain Practice 12:5, 399-412
  • Miles Day. (2001) Neurolysis of the Trigeminal and Sphenopalatine Ganglions. Pain Practice 1:2, 171-182
  • R SHAH. (2004) Long-term relief of posttraumatic headache by sphenopalatine ganglion pulsed radiofrequency lesioning: a case report1. Archives of Physical Medicine and Rehabilitation 85:6, 1013-1016
  • Sluder G.: The role of the sphenopalatine ganglion in the nasal headache N Y State J Med  1908; 27:8-13.
  • Todd D. Rozen. (2002) Interventional treatment for cluster headache: A review of the options. Current Pain and Headache Reports 6:1, 57-64. Online publication date: 1-Jan-2002.

Precautions

Warnings and Precautions

The Tx360® Nasal Applicator should be used with care only by trained healthcare professionals. Complications may include:

  • Nasal passage irritation. Putting anything repetitively in the nose may irritate the lining of the nose. To help avoid irritation, use the device for only a short duration on each side of the nasal passage. Do not use for more than one delivery. If the tissue the nose is bright red, appears to be irritated, or if the patient is experiencing pain, immediately discontinue using the Tx360® Nasal Applicator.
  • Nose bleeding. Do not force the tip of the Tx360® Nasal Applicator into the nose. Insert the device slowly and carefully following the step by step instructions described below. If a nose bleeding occurs, immediately stop using the device and hold pressure on the nose to stop bleeding.

Do not use the Tx360® Nasal Applicator in the following conditions (contraindications):

  •  If the patient has a nasal septal deformity such as the following: malformed facial or nasal passages such as cleft lip and palate, choanal atresia (narrowed nasal passages), atrophic rhinitis, rhinitis medicamentosa, septal perforation, nasal/midface trauma or if he has recently had nasal/sinus surgery.
    * Potential for injury may occur, such as nasal passage obstruction and nasal trauma and irritation.
  •  If the patient has a bleeding disorder such as Von Willebrand’s disease or hemophilia.
    * Uncontrolled bleeding may occur.
  •  If the patient has severe respiratory distress, as noted by breathing fast or pulling the stomach and rib muscles in when breathing.
    * Further irritation of nasal airway may worsen respiratory distress.
  •  If the patent has a Neoplasm such as the following: Angiofibroma, sinus Tumors, Granuloma.
    * Potential for injury may occur such as nasal passage obstruction and nasal trauma.
  •  Congestion has been present more than 10 days, there is a high fever, the nasal mucus is an abnormal color, or complains of face pain or headaches.

Do not use the Tx360® Nasal Applicator if:

  •  The skin around and inside the nasal passage is dry, cracked, oozing, or bleeding.
    * The Tx360® Nasal Applicator may cause nose bleeding and irritation when used in this condition.
  •  The patient has a nasal or facial fracture.
    * The Tx360® Nasal Applicator may cause additional nasal trauma.
  •  The Tx360® Nasal Applicator is a disposable device for Single Use Only. Not to Be Reused

Discard appropriately after use

Reuse of the Tx360® Nasal Applicator may cause serious infections and introduction of bacteria, such as:

  • VRE (Vancomycin-Resistant Enterococcus)
  • MRSA (Methicillin-Resistant Staphylococcus Aureus).