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Section Icon Sphenopalatine Ganglion Block
Overview
Targeted blocking of the sphenopalatine ganglion (SPG) is becoming more popular as an alternative to opioids for treating headaches, migraines, and other pain and neuralgias, although the literature is still mixed.1-5
It’s not completely understood why SPG blocking is effective
Indications
Acute and chronic cluster headaches
Acute or chronic migraine
Herpes zoster neuralgia involving the ophthalmic nerve
Persistent idiopathic facial pain
Trigeminal neuralgia
Various facial neuralgias
Contraindications
Allergy to anesthetic
Altered or unconscious patient
Infection within the intranasal canal
Equipment & Dosing
10-cm cotton-tipped applicator or syringe with mucosal atomizing device
  • Cotton-tipped applicators with a hollow stick allow additional anesthetic to be applied.
Lidocaine 4% (should be viscous lidocaine ONLY if using cotton-tipped applicator) or bupivacaine 0.5%
Sterile container to soak the applicator in the anesthetic
Anatomy & Innervation
The SPG is an extracranial parasympathetic ganglion with both parasympathetic autonomic and somatosensory fibers. Figure 1
The transnasal approach is ideal in the ED because it is safe and easy to perform at the bedside.
Procedure & Administration
Cotton-tipped applicator
Soak the cotton-tipped applicator in the anesthetic.
Place the patient in the sniffing position; some experts use the supine position.
Insert the applicator into the naris on the same side as the headache. If the patient is lying supine, insert it vertically.
Using steady pressure, continue to insert the applicator until you meet resistance at the posterior wall of the nasopharynx.
Leave the applicator in place 10 to 15 minutes.
If the patient is supine, you can add more drops of anesthetic down a hollow cotton-tipped applicator or into the nasal passage so drops run alongside the applicator down to the cotton swab.
The patient should experience significant improvement or resolution of symptoms.
Atomizing device
Draw up 1 mL of lidocaine 4% or bupivacaine 0.5%.
Fit device onto end of syringe.
Atomize a maximum of 1 mL per naris.
Reassess the patient after 10 minutes; the patient should experience significant improvement or resolution of symptoms.
Complications
Epistaxis
Numbness of the posterior pharynx
Sneezing
Charting & Documentation
An SPG block requires a procedure note in the medical record.
Document:
  • Clinical examination before the procedure
  • Sterile preparation and local antiseptic used
  • Needle approach and confirmation of needle placement
  • Type and dose of anesthetic injected
  • Clinical examination immediately after the procedure
  • Complications
Discharge Procedure
No special instructions are necessary.
Where to Learn More
ALiEM: “Trick of the Trade” on SPG
SonoSite: Ultrasound-guided nerve blocks
References
  1. Khan S, Schoenen J, Ashina M. Sphenopalatine ganglion neuromodulation in migraine: what is the rationale? Cephalalgia. 2014;34(5):382-391.
  2. Maizels M, Scott B, Cohen W, et al. Intranasal lidocaine for treatment of migraine: a randomized, double-blind, controlled trial. JAMA. 1996;276(4):319-321.
  3. Schaffer J, Hunter B, Ball K, et al. Noninvasive sphenopalatine ganglion block for acute headache in the emergency department: a randomized placebo-controlled trial. Ann Emerg Med. 2015;65(5):503-510.
  4. Cady R, Saper J, Dexter K, et al. A double-blind, placebo-controlled study of repetitive transnasal sphenopalatine ganglion blockade with tx360(®) as acute treatment for chronic migraine. Headache. 2015;55(1):101-116.
  5. Piagkou M, Demesticha T, Troupis T, et al. The pterygopalatine ganglion and its role in various pain syndromes: from anatomy to clinical practice. Pain Pract. 2012;12(5):399-412.

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Figure 1

Sphenopalantine Ganglion

Anatomy of the sphenopalatine ganglion and surrounding structures.

Figure 1 Image

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