New Nerve Block Procedure Effectively Treats Migraines
The SphenoCath procedure for establishing a sphenopalatine ganglion nerve block can provide rapid and significant pain relief to patients who present with intractable migraines that are refractory to prescribed therapies. The minimally invasive, in-clinic procedure is performed by many of the neurologists at Meritas Health Neurology, including Cynthia J. Ward, DO, Steven C. Kosa, MD and Larry C. Hollenbeck, MD. It is an urgent treatment option offered for migraine relief and to help patients avoid an Emergency Department visit.
The SphenoCath Procedure
The SPG nerve bundle, located deep within the nasal cavity, is part of the trigeminal nerve system, which is the major player in the pathogenesis of migraine headaches. The SphenoCath method involves administering a flexible catheter that delivers Lidocaine to a thin membrane overlying the SPG, sequentially into both nostrils. The patient lies with his/her head tilted back for five minutes as the anesthetic rapidly absorbs across the membrane to block the SPG nerve bundle which results in migraine pain relief.
Treatment side effects are minimal and include brief discomfort during the few seconds the catheter is in place, minor irritation of the nasal cavity post procedure and a feeling of numbness along with a temporary taste of anesthetic in the throat.
“The goal with the SphenoCath procedure is to revert patients who are in a severe, intractable migraine cycle back to their baseline pattern.”
“The goal with the SphenoCath procedure is to revert patients who are in a severe, intractable migraine cycle back to their baseline pattern. It effectively resets the trigemino-thalamic-cortical pain loop that made the attack refractory to traditional therapies such as nonsteroidal anti-inflammatory drugs and the triptan class of medications,” explained Dr. Ward.
The duration of pain relief varies by patient; many experience immediate relief and others sustained relief. The treatment plan involves adjusting a patient's daily prophylactic or as-needed medication regimens.
Getting the Lidocaine to the appropriate location is the key. Past approaches to blocking the SPG nerve have included:
1) using long, rigid Q-tips soaked in Lidocaine to drip anesthetic onto the ganglion
2) injecting Lidocaine through the side of the face using a needle directed to the deep portion of the nasal cavity.
Both techniques are difficult to perform and painful for the patient. The SphenoCath can deliver anesthetic directly to the SPG in a minimally invasive, safer, and more tolerable way.
SphenoCath Nerve Block Procedure
Analgesic overuse can lead to a vicious cycle of worsening migraines. “When analgesics are taken too frequently, patients can become dependent on them, the efficacy of the medicine is reduced and chronic migraines become even more difficult to treat,” Dr. Ward explained.
The American Academy of Neurology also discourages the use of the narcotic medication class or the commonly prescribed butalbital-containing products because they carry the highest risk of migraine conversion.
Dr. Ward advises primary care physicians to refer the following populations to a specialist:
- People with more than five migraines per month that require analgesic medication
- People who begin taking their prescription medication more frequently to control headache pain
- Patients whose previous therapies are no longer effective
The mainstays of migraine treatment involve educating patients about:
- Migraines, treatments options and why certain approaches are used
- The use of daily prophylactic medications such as botulinum toxin injections, anticonvulsants, antidepressants and blood pressure medication
- As-needed abortive medications including NSAIDs and triptan medications, including:
- Delivery options (oral, nasal, injection)
- The level of effectiveness
“When abortive medications are not effective and patients turn to the ED, they may receive intravenous medications that contribute to the conversion to chronic migraine,” Dr. Ward explained. “We want to help patients avoid that painful loop.”
Expanding Treatment Options
In addition to urgent block procedures such as SphenoCath, new devices for nerve stimulation are coming to the market. The new treatment option Calcitonin Gene-related Peptide may soon be available, which will expand physicians’ armamentarium of migraine treatments.
SPG blocks are often used intermittently as a prophylactic treatment option for people who cannot receive or tolerate botulinum toxin injections. Additionally, SPG blocks may be an option for people whose migraines are treated with Botox. “Botulinum injections are approved to be administered every 12 weeks but often wear off after 10, leading to a two week vulnerability period where migraine attacks are more likely to occur,” Dr. Ward said. “The SphenoCath procedure can be performed during this time to bridge the gap between Botox injections.” Lastly, the procedure can also treat patients with the severe headache syndromes of cluster headaches and trigeminal neuralgia.
Other Nerve Block and Muscle Injection Options
Other nerves can be blocked in addition to the SPG depending upon where the migraine is located including the following:
- Occipital - Back of the head
- Auriculotemporal - Side of the head
- Supraorbital and supratrochlear – Above and behind the eyes
- Trigger point muscle injections into the neck and trapezius muscles
Each type of block disrupts the pathways that cause severe migraines. “We offer patients with severe migraine pain same-day appointments as a way to help avoid the ED,” Dr. Ward said. “Almost invariably, whether I use an SPG block, an occipital block or a combination of nerve blocks, patients demonstrate significant improvement in their headache by the time they leave the office.”
Cynthia J. Ward, DO
Dr. Ward received her medical training at the Kansas City University of Medicine and Biosciences. She completed her preliminary year of internal medicine at the University of Oklahoma in Tulsa, OK, and her neurology residency at The University of Kansas Medical Center.