Download SPG and Migraine - Dr. Barry Glassman Seminars

Slide 1
Sphenopalatine Ganglion
Anesthetic Block for
Treatment of Intractable
Migraine and Cluster
John E. Castaldo MD
Professor and Chief of Neurology
College of Medicine USF
Timothy M. Breidegam Endowed
Chair in Neurology
Lehigh Valley Health Network
Slide 2
Anatomy
of
SPG
Slide 3
ssSs
SPG

spg
Slide 4
Slide 5
Slide 6
Slide 7
Structure
The Spenopalatine ganglion is the largest of the parasympathetic
ganglia associated with the branches of the Maxillary Nerve
It is triangular or heart-shaped, of a reddish-gray color, and is situated
just below the Maxillary nerve as it crosses the fossa.
Supplies the lacrimal gland, paranasal sinuses, glands of the mucosa of
the nasal cavity and pharynx, the gingiva, and the mucous membrane
and glands of thehard palate. It communicates anteriorly with
the nasopalatine nerve.
Slide 8
Roots
Receives Sensory parasympathetic and
sympathetic input
Sensory root derived from two
sphenopalatine branches of the maxilary
nerve
Parasympathetic root is derived from the
nervus intermedius of the facial nerve
through the greater petrosal branch
Slide 9
Slide 10
Connections to CNS
Slide 11
Possible Sites of Action of Triptans
in the Trigeminovascular System
Possible Sites of Action of Triptans
in the Trigeminovascular System
Goadsby PJ, et al. N Engl J Med. 2002;346:257-70. Reprinted with permission.
Slide 12
Pathophysiology of Migraine
Goadsby PJ, et al. N Engl J Med. 2002;346:257-70.
Slide 13
BOLD
MRI
WMA
Slide 14
MRI
and
stroke
PET
Slide 15
Slide 16
Slide 17
Patterns of Use of Peripheral
Nerve Blocks and Trigger Point
Injections Among Headache
Practioners in the USA: Results
of the American Headache
Society Interventional
Procedure Study
Avi Ashkenazi et al
 Headache 2010;50:937-942

Slide 18
Slide 19
Slide 20
Anatomy of Cranial Occipital
Nerves
Slide 21
Slide 22
Ashkenazi et al 2010

. CCH = chronic cluster headache; CM = chronic migraine; CTTH =
chronic tension-type
; ECH = episodic cluster; ETTH = episodic
tension-type headache; HC = hemicrania continua; MA =
migraine with aura; MO = migraine without aura; NDPH = new
daily persistent headache; ON = occipital neuralgia; SM =
status migrainosus.
Slide 23
Indications for use of GON Block
Slide 24
Peripheral Nerve Block Locations





For greater and lesser ONBs
For supraorbital nerve and
infraorbital nerve blocks
.
Few participants performed
auriculotemporal nerve blocks. s
or

responders used the occipital
ridge, the occipital notch, or
midway between the occipital
protuberance and mastoid.

delivered at the supra- and
infraorbital notch or depression

tended to localize the nerve
relative to the tragus or
zygomatic arch

Localized by palpation
The supratrochlear nerve was
also rarely injected
Slide 25
Peripheral Nerve Blocks Outcome
Judged successful by 89% if headache
resolved in the days following
 Judged successful by 68% if headache
resolved following the injection
 Percent of injections judged successful by
either criteria? Unknown

Slide 26
Sphenopalatine Block
Intranasal with marcaine soaked pledgets
 Infrazygomatic lateral approach through
salivary glands
 Suprazygomatic lateral approach: Glassman
procedure.

Slide 27
Glassman Procedure: set up
5 CC syringe
 22 g 2 inch needle
 Mixture of 0.5% Ropivacaine (4 cc) and 40
mg of Methylprednisolone (1cc)
 Patient lying in the lateral decubitus position
 An assistant to offer reassurance
 Alcohol and gauze pads and ice pack
 5 minutes to prepare, 2 minutes to inject

Slide 28
Glassman procedure
Patient is asked to stay in the lateral
decubitus position for ten minutes (injected
side up)
 Then turn to lying on the back 5 minutes
 Then sitting up semi recumbent position for 5
minutes until pain is relieved

Slide 29
SPG Block: Glassman
Slide 30
Note position and maxillary art
Slide 31
Patient Comfort
No patient reported the procedure as
“painful” enough as to have wished it wasn’t
done.
 Most rated it associated with a mild
discomfort no greater than 2-3 on a scale of
1-10.
 Some rated 0 discomfort with the procedure
in comparison to their level of headache
pain.
 All patients found immediate relief of nausea,
vomiting and sensitivity to sound and light.

Slide 32
Results of SPG block prior to
DC from the office
Complete pain relief
16%
 Pain reduction 3 pointsLeichert scale 46%
 Pain reduction of 3-6 points
31%
 Pain reduction of greater than 50%
37%
 No Relief whatsoever
1%


NB: Pain relief by Leichert Scale 1-10 and
measured at 20 minutes after injection
Slide 33
Patient Selection
Status Migrainosis refractory to steroids,
DHE , triptans and narcotics
 Chronic Migraine refractory to multiple
medications including Botox
 Cluster refractory to Prednisone. Lithium and
Valproic acid
 Hemicrania continua
 New Daily Persistent Headache
 Pain level of 7-10 at time of procedure

Slide 34
PAIN LEVEL REDUCTION WITH
SPG BLOCK n=146; 2008-12
Slide 35
# of
Name
update
ND
Kathryn W
David H
Sharon H
Sarah M
Beverly A
Kama N
Machelle
Karen D
Denise S
George B
Danine S
Multiple SPG Blocks
MRN#
149980
1185525
1375873
00450464
1196876
1394774
00597342
00217610
00218321
1567412
00681442
injections
6
4
3
5
4
4
8
11
3
4
4
4
Bilat
Bilat
Bilat
bilat
bilat
uni
uni
uni
bilat
uni
bilat
bilat
Bilat/uni
chronic mig
chronic mig
migraine
hemicrania continua
chronic mig
chronic mig
chronic mig
chronic mig
chronic mig
cluster/ mig
chronic mig Botox
chronic mig
Slide 36
Case Study: 44 year old woman
Hx: Migraine with aura all her life starting at
menarche
 Increasing severity and frequency over 10
years.
 Concern over deviated septum and “chronic
sinus headache” ENT evaluation negative
 Frequency Daily
 Severity 8-10
 Treating with 100 Exedrine per week.

Slide 37
HA profile

CHARACTER: The pain feels like " Burning in cheeks, like I have a
pulse in my eyeballs) “ ice picks to biparietal regions

AURA:with migraine spots

Location: right anterior quadrant of head predominant

ASSOCIATED SYMPTOMS:face and scalp sensitivity. skin in the
nose and over face hurts at times.

AUTONOMIC FEATURES:nausea and vomiting and light sensitivity
and sound sensitivity

TRIGGERS:light, bacon, stress, menses odors can trigger.
Slide 38
HA profile cont.

EXERTIONAl: makes both types of headaches worse.

SLEEP HYGEINE:can't sleep well. Can fall asleep

STRESS: High stress "normal everyday"

SOCIAL LIFE:withdrawn from friends because of daily pain

ANXIETY: high anxieyt all the time.

DEPRESSION:She feels sad and easily becomes tearful

ESTROGEN CYCLES: worse
Slide 39
HA Profile
FAILED MEDS:Cymbalta, physical therapy,
yoga, pilates. Flexeril, tramadol toradol
injections.skelaxin , valium, xanax, topamax
and Amitriptyline, Nortriptyline,Cymbalta,
Effexor, Zoloft, steroids, IV narcotic
 Imitrex minimally helpful


Other symptoms: Positional vertigo
worsening over the last 10 months
Slide 40
Therapy
Lamictal advance to 150 bid
 Get off OTC analagesic meds
 Migraine hygeine
 Brief course of steroids and ergot therapy
 Trazodone therapy for sleep and HA
 Epley maneuver

Slide 41
Abnormal MRI
Slide 42
Outcome
Chronic Daily Headache persists
 Could not tolerate Trazodone self DC
 Vertigo cleared
 Ice pick pain better
 Depression remains high
 Anxiety high
 Appears in office in excruciating pain with
nausea and vomiting.

Slide 43
Therapy
Right SPG anesthetic nerve block using 1 cc
of 40 mg depomedrol and 4 CC 0.5 %
Ropivacaine.
 Fluoxetine 20 mg daily initiated
 Lamictal continued at 150 mg po bid
 Maxalt for break through pain

Slide 44
Outcome
“I have my life back”
 No significant headaches for 3 months since
SPG injection
 No vertigo since Epley maneuver
 No ice pick pain
 Bipolar symptoms clear
 Depression markedly improved
 Sleep architecture improved.

Slide 45
Conclusions:
SPG injections are safe, well tolerated and
effective abortive therapy for migraine and
cluster headaches
 Glassman approach is better tolerated that
trans nasal by most patients
 Most patients achieve and immediate 50100% reduction in pain in 20 minutes with
better results evolving over hours to days
 Durability of relief is variable lasting days to
months in most

Slide 46
Conclusion Continued
Best results appear to be in patients with
unilateral anterior quadrant head pain
centered over temple, forehead and eye.
 Results are superior to auriculotemporal
nerve blocks in combination with occipital
nerve blocks, the gold standard of cranial
block therapy
 Best results obtained with comprehensive
preventive headache therapy including diet,
exercise, preventive/abortive meds, psych
and attention to sleep architecture

Slide 47
Next steps
Randomize clinical trial comparing GON
block to SPG block in refractory pain patients
 Quantitative long term evaluations of post
procedure pain relief.
 Identification of headache subtypes most
responsive to procedure
 Assess for long term complications, if any

Slide 48
Questions?