Severe Bruxism/ Neuromuscular Dentistry/ Dental Sleep Medicine/ TrigeminoCardiac Reflex and SPG Blocks are all connected and part of the same system

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What is the common underlying link of all of these.  The Trigeminal Nerve and the Autonomic nerves of thee Sphenopalatine Ganglion.
Self-Administered SPG Blocks can improve many autonomic issues in patients.
This is the connection of TMJ disorders to problems with the gut.
The connection of Aiirway collapse secondary to dental issues has been well established.
Bruxism is far more than a habit it is part of a medical group of disordrs.
. 2018 Aug; 4(8): 329–331.
Published online 2018 May 18. doi:  [10.1016/j.hrcr.2017.06.013]
PMCID: PMC6092563
PMID: 30112280

Grinding to a halt: Stimulation of the trigeminal cardiac reflex from severe bruxism

Key Teaching Points

  • • The autonomic nervous system has an intricate relationship with the heart; severe vagal stimulation can produce bradycardia and asystole.
  • • The trigeminal cardiac reflex is a powerful brain stem reflex that can be associated with a sudden onset of parasympathetic dysrhythmia, sympathetic hypotension, or gastric hypermotility.
  • • Bruxism, which is reported in 8% of the population, can stimulate the trigeminal cardiac reflex and lead to profound vagal effects on the heart.

Introduction

The trigeminal cardiac reflex (TCR) is a unique, powerful, and well-established neurocardiogenic reflex that is a result of stimulation along the path of the fifth cranial nerve (trigeminal nerve). It can produce adverse cardiorespiratory changes including hypotension, bradycardia, and asystole, as well as gastric consequences such as hypermotility. This reflex has been reported to occur in various surgical conditions, as well as in neurosurgical interventions.

Sleep bruxism, thought to be a more intense form of rhythmic masticatory muscle activity, has a prevalence of about 8% and has been explicitly linked to the TCR.We report a case of a young woman with severe bruxism who incited her TCR, which subsequently produced profound nocturnal pauses that ultimately required dual-chamber pacemaker implantation.

Case report

A 27-year-old woman presented with palpitations and syncope. Three years prior to presentation she developed nocturnal and early morning nausea and vomiting that would often wake her from sleep. She was noted to have a long-standing history of severe bruxism with physical signs on examination of significant attrition. This had persisted despite the use of a retainer and bite block. Evaluation with Holter monitoring revealed sinus bradycardia, intermittent second-degree type II atrioventricular (AV) block, and a pause of 8.6 seconds (Figure 1). Interestingly, the rhythm strips showed simultaneous effects on both the sinus and AV node, suggesting an autonomic etiology. Of note, these rhythm disturbances were principally nocturnal in nature. While she was wearing the Holter, the husband was awake and corroborated that she was having severe episodes of bruxism. Further cardiac evaluation was unrevealing, including a normal echocardiogram, cardiac magnetic resonance imaging, sleep study, and thorough autonomic testing. With her constellation of symptoms—severe bruxism, AV nodal block with cardiac pauses (that were predominantly nocturnal), and gastrointestinal symptoms—we diagnosed her with hypervagotonia from stimulation of the powerful TCR from severe bruxism (Figure 2). Out of concern for risk of cardiac death from these pauses without a stable ventricular escape, we elected to place a dual-chamber pacemaker for bradycardic prevention.

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Holter monitoring revealed sinus bradycardia, intermittent second-degree type II atrioventricular block, and a pause of 8.6 seconds

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Illustration of the trigeminal cardiac reflex. X = motor nucleus of the vagus nerve; ∗ = Gasserian ganglion; V = trigeminal nerve.

Discussion

This case highlights the intricate and noteworthy relationship between the autonomic nervous system and the heart. Our patient developed high-grade AV block and syncope owing to significant and profound hypervagotonia. Based upon her evaluation and corroboration of these events by her husband, we deemed that her intense vagal stimulation was a consequence of her severe bruxism, which was eliciting the TCR.

The TCR (Figure 2) is a powerful brain stem reflex that can be associated with a sudden onset of parasympathetic dysrhythmia, sympathetic hypotension, or gastric hypermotility. The proposed mechanism of this reflex is stimulation of the sensory nerve endings of the trigeminal nerve (Figure 2, cranial nerve V), which sends signals via the Gasserian ganglion (Figure 2, indicated by asterisk) to the sensory nucleus of the trigeminal nerve (Figure 2 inset). The afferent pathway then continues along the short internuncial nerve fibers in the reticular formation to connect with the efferent pathway, the motor nucleus of the vagus nerve (Figure 2, cranial nerve X). The last part of the reflex is formed by cardioinhibitory efferent fibers, which connect the motor nucleus of the vagus nerve to the myocardium.

Bruxism is a common occurrence in the population (8%) and has been associated with alterations in the autonomic nervous system and stimulation of the TCR. The mechanism behind the TCR stimulation is felt to be 2-fold. Firstly, masticatory movements (rhythmic masticatory muscle activity) and secondly, teeth contact can stimulate mechanoreceptors in the periodontal tissue. The link between bruxism, TCR, and alteration in the autonomic nervous system is important to highlight as it is well established that the autonomic nervous system plays a critical role in the pathogenesis of various cardiac arrhythmias, particularly atrial fibrillation. Although not specifically related to our patient, the fact that bruxism is so common raises the potential role it could be contributing to autonomic drivers of atrial fibrillation, and this is something that requires further research examination.

Conclusion

When evaluating patients who present with symptoms of significant hypervagotonia, it is important to consider sleep-related causes, in particular sleep bruxism and its role in the TCR.

Footnotes

Dr DeSimone is supported by an NIH T32 training grant (HL 007111).

References

1. Reding G.R., Rubright W.C., Zimmerman S.O. Incidence of bruxism. J Dent Res. 1966;45:1198–1204. [PubMed]
2. Schames S.E., Schames J., Schames M., Chagall-Gungur S.S. Sleep bruxism, an autonomic self-regulating response by triggering the trigeminal cardiac reflex. J Calif Dent Assoc. 2012;40:670–671. 674–676. [PubMed]
3. Arasho B., Sandu N., Spiriev T., Prabhakar H., Schaller B. Management of the trigeminocardiac reflex: facts and own experience. Neurol India. 2009;57:375–380. [PubMed]
4. Gastaldo E., Quatrale R., Graziani A., Eleopra R., Tugnoli V., Tola M.R., Granieri E. The excitability of the trigeminal motor system in sleep bruxism: a transcranial magnetic stimulation and brainstem reflex study. J Orofac Pain. 2006;20:145–155. [PubMed]
5. Chowdhury T., Bindu B., Singh G.P., Schaller B. Sleep disorders: is the trigemino-cardiac reflex a missing link? Front Neurol. 2017;8:63. [PubMed]
6. Sjoholm T.T., Piha S.J., Lehtinen I. Cardiovascular autonomic control is disturbed in nocturnal teethgrinders. Clin Physiol. 1995;15:349–354. [PubMed]
7. Okada Y., Kamijo Y., Okazaki K., Masuki S., Goto M., Nose H. Pressor responses to isometric biting are evoked by somatosensory receptors in periodontal tissue in humans. J Appl Physiol. 2009;107:531–539. [PubMed]

Sinus Headache, Sinusitis, Sinus Pain and TMJ Disorders

Dr. Shapira Blog, Chicago, Highland Park, Lake Bluff, Lake Forest, Libertyville, TMJ, Uncategorized 0 Comments

Chronic Sinus Headache and other Sinus Pains are closely related to TMJ Disorders. The connections between these problems is multifacted.

The Trigeminal Nerve also called the Dentist’s Nerve is the underlying common source of all of these problems.

Dentists are the experts on the Trigeminal Nerrve Disorders and in particular neuromuscular dentists who optimize eliminating noxious input to the trigeminal system. The term “TMJ: The Great Imposter” was coinded because patients with TMJ disorders frequently report symptoms not specifically related to the joints.

Dentists who practice TMD and Neuromuscular Dentistry are well versed in Myofascial Pain and Dysfunction or MPD as it relates to upper body, head neck and facial pain referred from active myofascial trigger points.

The Sphenopalatine Ganglion (SPG), the largest parasympathetic ganglion in the head is on the maxillary division of the trigeminal nerve. I have taught hundreds of neuromuscular dentists both from the USA and from across the world how to utilize SPG Blocks as part of Neuromuscular Treatment.

The Sphenopalatine Ganglion also contains Sympathetic fibers of superior cervical change responsible for “Fight or Flight” reflex and when not controlled create a wide variety of stress, pain and emotional issues.

The Myomonitor utilized by Neuromuscular Dentistry effectively neuromodulates the sympathetic and parasympathetic autonnomic input from the Trigeminal Nervous System.

The majority of sinus pain and sinus headache are NOT primary issues or infections within the sinuses. Antibiotics may actually create new sinus issues related to fungal infections.

Sinus pain and Headaches can be relieved with SPG Blocks very quickly.

Long term sinus improvements are related to function and structure.  The following is a video of a patient who has experienced a cure of her lifetime sinus issues with DNA Appliance.  Neuromuscular Dentistry treated her TMJ disorders and the DNA is used for long term stabilization and to increase the size of her airway.

There are over 150 additional videos on treatment of TMJ Disorders, Headaches, Migraines, MPD, Fibromyalgia, Sinus pain, Sleep Apnea and snoring mat this link:  https://www.youtube.com/channel/UCk9Bfz6pklC7_UluWFHzLrg/videos

 …

The Sphenopalatine Ganglion Block for Relief of Facial Pain from the Nasal Mucosa.

Dr. Shapira Chicago, Highland Park, TMJ, Uncategorized 0 Comments

This new article in Cranio (abstract below) discusses use of SPG Blocks in treating Facial Pain of Nasal Origin. I teach patients to self administer these block for many types of headache and facial pain.

This specific case was due to a nasal contact headache where the nasal turbinate is touching the septum.

Another approach is to grow the underdeveloped maxilla to open up airway, decrease sinus pain and infections while improving breathing.

This video is a patient who has used SPG Blocks in the past but is now making permanent changes in her nasal airway to improve health including TMJ disorder with the DNA Appliance and Epigenetic orthopedics/ orthodontics.

Cranio. 2018 Jun 8:1-3. doi: 10.1080/08869634.2018.1475859. [Epub ahead of print] Efficacy of sphenopalatine ganglion block in nasal mucosal headache presenting as facial pain.
Lee SH1, Kim Y1, Lim TY1.
Author information
Abstract
Background When intranasal contact points are the cause of headache and facial pain, opinions regarding whether to remove intranasal contact points when they are believed to be the cause of headache and facial pain are divided. Clinical Presentation A 46-year-old woman visited the authors’ pain clinic with complaints of right nasal pain accompanied by frontotemporal headache. She first met an Otorhinolaryngologist and a neurologist. Based on nasal endoscopy and pain pattern, they presumed that her pain was a nasal mucosal headache rather than migraine. A mild septal deviation to the right side with bony spur near the inferior turbinate was observed. The use of medication provided very insufficient relief. However, the sphenopalatine ganglion (SPG) block provided excellent pain relief, and the effect lasted for six months. Conclusion Considering the mechanism of pain in intranasal contact point headache, (SPG) block is a potentially effective therapeutic tool.

KEYWORDS:
Sphenopalatine ganglion block; facial pain; nasal mucosal headache; trigeminal afferent nerves…

Acute Migraine: Sphenopalatine Ganglion Blocks (SPGB) Safe and Effective. Self Administration is a Patient Friendly Approach

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A new article published in 208 discusses utilization of Sphenopalatine Ganglion Blocks for treatment of Severe Migraine.  Because it is published byty.the US National Library of Medicine of the National Institute of Health I can reprint it here.

I will make my personal comments in ALL CAPITAL LETTERS.  I ALSO FIND THAT SPG BLOCKS  CAN TREAT MANY OTHER DISORDERS INCLUDING FIBROMYALGIA, NECK, BACK, TMJ DISORDERS, TMD AND SHOULDER PAINS.

SELF-ADMINISTRATION OF SPG BLOCKS SHOULD BE CONSIDERED BY ALL PATIENTS WITH CHRONIC HEAD AND NECK PAIN, CLUSTER HEADACHES, ACUTE MIGRAINES, SINUS PAIN, SINUS HEADACHE AND EYE PAIN.  THIS DOES NOT MEAN THAT NEW PAIN SHOULD NOT BE EVALUATED BY APPROPRIATE PHYSICIANS AND SPECIALISTS.

INTRESTING NEW STUDIES HAVE SHOWN SPG BLOCKS ELIMINATING ESSENTIAL HYPERTENSION IN ONE THIRD OF PATIENTS.

. 2018; 2018: 2516953.
 Published online 2018 May 7.
Sphenopalatine Ganglion Block for the Treatment of Acute Migraine Headache

Abstract

Transnasal sphenopalatine ganglion (THE SPHENOPALATINE GANGLION IS ALSO KNOWN AS THE PTERYGOPALATINE GANGLION, MECKEL’S GANGLIO, THE NASAL GANGLION AND SLUDER’S GANGLION) block is emerging as is an attractive and effective treatment modality for acute migraine headaches, cluster headache, trigeminal neuralgia, and several other conditions.  We assessed the efficacy and safety of this treatment using the Sphenocath® device. 55 patients with acute migraine headaches underwent this procedure, receiving 2 ml of 2% lidocaine in each nostril. (2% LIDOCAINE HAS ANTIINFLAMATORY PROPERTIES AND HAS VERY FAVORABLE SAFETY PROFILE)  Pain numeric rating scale (baseline, 15 minutes, 2 hours, and 24 hours) and patient global impression of change (2 hours and 24 hours after treatment) were recorded. The majority of patients became headache-free at 15 minutes, 2 hours, and 24 hours after procedure (70.9%, 78.2%, and 70.4%, resp.). The rate of headache relief (50% or more reduction in headache intensity) was 27.3% at 15 minutes, 20% at 2 hours, and 22.2% at 24 hours. The mean pain numeric rating scale decreased significantly at 15 minutes, 2 hours, and 24 hours, respectively. Most patients rated the results as very good or good. The procedure was well-tolerated with few adverse events. This treatment is emerging as an effective and safe option for management of acute migraine attacks.  THE EXCELLENT AND RAPID RESPONSE IS EXTREMELY FAVORABLE HOWEVER PATIENTS MUST GO TO THE EMERGENCY DE3PARTMENT OR PHYSICIANS OFFICE TO BE TREATED.  A BETTER APPROACH IS TO TREAT THE PATIENTS TO SELF ADMINISTER THE BLOCKS TO STOP THE MIGRAINE EARLY OR PREVENT IT COMPLETELY IF THE BLOCK IS DONE DURING PRODROME.

THE SPHENOPALATINE GANGLION BLOCK WAS ORIGINALLY DESCRIBED BY SLUDER IN 1908.  DR GREENFELD SLUDER WROTE A TEXTBOOK NASAL NEUROLOGY AND BECAME CHAIR OF OTOLARYNGOLOGY AT WASHINGTON UNIVERSITY MEDICAL SCHOOL IN ST LOUIS.A   A 930 ARTICLE IN THE ANNALS OF INTERNAL MEDICINE BY HIRAM BYRD MD REPORTED ON 10,000 BLOCKS ON 2000 SEPERATE PATIENTS WITH VIRTUALLY NO ADVERSE EFFECTS.  UNFORTUNATELY, THE SPHENOPALATINE GANGLION BLOCK BECAME A VICTIM OF FORGOTTEN MEDICINE WHEN DRUG COMPANIES CREATED A STORM OF PHARMACEUTICALS.  THE SAFETY PROFILE OF THESE DRUGS DO NOT APPROACH THAT OF SPG BLOCKS WITH 2% LIDOCAINE.  A 1986 BOOK ‘MIRACLES ON PARK AVENUE” WAS PROBABLY RESPONSIBLE FOR THE GRADUAL RESURGENCE OF THIS EXCELLENT TECHNIQUE.  THE BOOK DESCRIBED THE NYC PAIN PRACTICE OF DR MILTON REDER AND ENT WHO UTILIZED ONLY SPG BLOCKS TO TREAT A WIDE VARIETY OF PAINFUL CONDITIONS REGARDLESS OF UNDERLYING DIAGNOSIS.

1. Introduction

Migraine is a common primary headache disorder, causing significant disability and personal, societal, and financial burden (SELF ADMINISTRATION OF SPG BLOCKS CAN SIGNIFICANTLY REDUCE COSTS IN TERMS OF EXPENSES, LOST WORK AND SUFFERING) []. It is a highly prevalent condition, affecting 11% of adult population worldwide, including people of all ages, races, geographical areas, and income levels []. Although there are currently many options for acute migraine treatment, such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDS), triptans, combinations analgesics, and antiemetics [], these treatment options are often (MORE OFTEN THAN NOT)  suboptimal, with inadequate efficacy and significant side effects []. In addition, several studies [] have shown that migraine patients with poor response to acute treatment are at increased risk for transformation to chronic migraine (CM) (SPG BLOCKS ARE ALSO EFFECTIVE AT TREATING CHRONIC MIGRAINE BUT EARLY INTERVENTION IS STILL THE BEST ROUTE) , with roughly 2.5-3.5-fold greater odds of developing CM []; patients with a moderate or better acute treatment efficacy did not have a significant increased risk. Therefore, there is a continuous need for new treatment modalities to address the therapeutic needs of migraine sufferers, especially those with frequent and disabling attacks [].

Sphenopalatine ganglion (SPG) block has gained interest as an effective treatment modality for migraine and other headache and facial pain syndromes []. SPG, also known as the pterygopalatine ganglion (PPG), is a large extracranial parasympathetic ganglion (THE SPG IS THE LARGEST PARASYMPATHETIC GANGLION OF THE HEAD)with multiple neural connections (Figure 1), including autonomic, motor, and sensory []. This complex neural structure is located deeply in the pterygopalatine fossa (PPF) posterior to the middle turbinate and maxillary sinus [], on each side of the face. The parasympathetic preganglionic cell bodies originate in the superior salivatory nucleus in the pons, and the parasympathetic fibers run in the nervus intermedius (a branch from the facial nerve) through the geniculate ganglion, forming the greater petrosal nerve (GPN). The sympathetic fibers originate in the superior cervical ganglion (THE SYMPATHETIC FIBERS OF THE SUPERIOR CERVICAL SYMPATHETIC CHAIN ARE VERY IMPORTANT IN THE ABILITY OF THESE BLOCKS TO TURN OFF THE “FIGHT OR FLIGHT” REFLEX) around the internal carotid artery and give rise to the deep petrosal nerve, which joins the GPN to form the Vidian nerve, which enters the SPG. The sensory input to the SPG is via branches from the maxillary nerve, carrying sensations from the palate, buccal cavity, gingival, and tonsils [].

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Saggital view of the nasopharynx, showing the sphenopalatine ganglion and its neural connections. Reproduced with permission from Robbins et al. (2016) [under the Creative Commons Attribution License number 4318850197898 (Wiley).

The parasympathetic fibers synapse in the SPG and second-order neurons provide secretomotor function to the mucous membranes of nose, mouth, pharynx, and lacrimal glands, as well as branches to the meningeal and cerebral blood vessels []. The sympathetic fibers pass through the SPG without synapsing and provide innervations to the palate, nasal cavity, and pharynx.

As acute migraine attacks, as well as other primary headache disorders like cluster headache, are often associated with signs of parasympathetic activation, including lacrimation, nasal congestion, and conjunctival injection, blocking the SPG, which is the major parasympathetic outflow to the cranial and facial structures, is a reasonable target to help relief pain and autonomic features seen in these disorders []. It is proposed that various migraine triggers activate brain areas related to superior salivatory nucleus, leading to stimulation of the trigemino-autonomic reflex. This results in increased parasympathetic outflow from the SPG, causing vasodilatation of cranial blood vessels that happens during migraine [], with the release of inflammatory mediators from blood vessels and activation of meningeal nociceptors, causing migraine pain []. Another possible effect of SPG block is modulation of sensory processes in the trigeminal nucleus caudalis via the afferent sensory fibers, which may change pain processing center and reduce central sensitization to pain that is commonly seen in migraine [].

SPG blocks have been used for the treatment of headache since a long time []. In 1908, Sluder described the use of transnasal SPG block using a long needle to inject cocaine, treating what was called Sluder’s neuralgia []. The technique was further developed by Simon Ruskin [], and in 1925 he used it to treat trigeminal neuralgia. Since then, the indications for SPG block have expanded to include cluster headache, migraine, trigeminal neuralgia, and many more [].

SPG blocks have been achieved with various techniques, including the use of lidocaine-soaked cotton tip applicator through the nose, transorally, transnasal endoscopic, infratemporal approach, and more recently using various noninvasive transnasal devices to inject anesthetics into the SPG [].

The objective of this study is to assess the efficacy of SPG block, using the Sphenocath device, for the treatment of acute migraine headaches in the outpatient setting. We also report the safety of this novel technique for migraine treatment.

2. Methods

2.1. Study Design and Setting

We conducted an open, uncontrolled, retrospective study in the neurology clinic at a university medical center. The patients were treated between March 2017 and September 2017. The study was approved by the institutional review board of University Medical Center at King Abdullah Medical City.

2.2. Study Population

The patients were recruited to the study if they were between 18 and 60 years of age, have been diagnosed with migraine headache according to International Classification of Headache Disorders-3 Beta [] since at least one year, and present with moderate to severe headache lasting between 4 and 72 hours not responding to abortive medications. Patients with medication overuse headache, bleeding disorders, abnormal neurological examination, and history of allergy to local anesthetics were not included in the study. All patients gave an informed written consent.

2.3. Methods of Measurement

Pain was assessed using numeric rating scale (NRS), where 0 is no pain and 10 is worst pain imaginable; this was recorded at baseline, 15 minutes, 2 hours, and 24 hours after the procedure. We also recorded patient global impression of change (PGIC; very poor, poor, no change, good, and very good) at 2 hours and 24 hours after procedure.

2.4. Outcome Measures

The primary efficacy measure was the percentage of patients free of headache at 15 minutes, 2 hours, and 24 hours after the procedure. Secondary endpoints were

  1. headache relief rate, defined as percentage of patients with 50% or more reduction in headache intensity at 15 minutes, 2 hours, and 24 hours;
  2. change in NRS from baseline to 15 minutes, 2 hours, and 24 hours after treatment;
  3. PGIC (effects on headache and its associated symptoms and tolerability) at 2 hours and 24 hours;
  4. all adverse events up to 24 hours after procedure.

Statistical analysis was done using SPSS Statistics Version 23.

3. Procedure

Prior to procedure, the nose was inspected for any obstruction, and xylometazoline 0.05% nasal drops( AFRIN NASAL SPRAY, OXYMETAZOLINE SPRAY IS EXTREMELY EFFECTIVE IN SHRINKING NASAL MUCOSAL TISSUES) ) (one drop in each nostril) were used to help open the nasal passages. Face temperature was recorded using temperature sensor skin probes put on both cheeks. A small amount of 2% lidocaine jelly was installed in each nostril for patients’ comfort, using a needless syringe. (AN ALTERNATIVE IS TO USE 2% LIDOCAINE IN A SPRAY FORM ONE MINUTE BEFORE PLACEMENT) Each patient received a single treatment of transnasal SPG block with 2 cc of 2% lidocaine in each nostril in the supine position with head extension, delivered using the Sphenocath device.  (I UTILIZE PRIMARILY A COTTON-TIPPED NASAL CATHETER THAT ALLOWS CONTINUAL CAPILLARY FEED OF LIDOCAINE FOR MOST PATIENTS.  I ALSO UTILIZE THE SPHENOCATH AND THE TX360 DEVICES IN MY OFFICE.  THE ALLEVIO DEVICE IS SIMILAR TO THE SPHENOCATH DEVICE) This is a small flexible sheath with a curved tip (Figure 2). It is inserted through the anterior nasal passage parallel to nasal septum and above the middle turbinate. Once in place, the inner catheter is advanced to administer 2 cc of 2% lidocaine. It is then removed and the procedure is repeated on the other side. Typically after the block, there is an increase in face temperature by 1 to 2 degrees Celsius and/or tearing []. The patient is instructed to remain in the same position for 10 minutes.  GENERALLY THERE IS LESS DISCOMFORT WITH THE COTTON TIPPED CATHETER BUT IN SOME PATIENTS WITH DIFFICULT ACCESS I UTILIZE DEVICE DELIVERY.

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ATERAL APPLICATIONThe Sphenocath device. Image provided courtesy of Dolor Technologies.

4. Results

55 patients received treatment with bilateral transnasal SPG blocks. 72.7% were females. The age range of patients was 19 to 58 years, with a mean age of 37.9 years. The baseline NRS range was 4 to 10, with a mean of 6.8. For the primary end point (headache freedom at 15 minutes, 2 hours, and 24 hours), the percentages were 70.9%, 78.2%, and 70.4%, respectively (Figure 3). Among the secondary efficacy measures, 27.3%, 20%, and 22.2% of patients reported headache relief at 15 minutes, 2 hours, and 24 hours after the procedure, respectively (Figure 3).  THE RAPID RELIEF IS TYPICAL OF PATIENTS RECEIVING SPG BLOCKS REGARDLESS OF THE METHOD OF DELIVERY.  THE COSTS OF THE DEVICES ARE HIGH APPROXIMATELY $75.00.  I PREFER THE COTTON-TIPPED NASAL CATHETERS WHICH COST LESS THAN $1.00 PER BILATERAL APPLICATION.  MORE IMPORTANT THEY ARE VERY EASY FOR MOST PATIENTS TO UTILIZE FOR SELF ADMINISTRATION AT HOME.

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The percentage of patients reaching headache freedom (pain numeric rating scale 0) and patients with headache relief (50% or more reduction in headache intensity), at 15 minutes, 2 hours, and 24 hours.

The mean NRS scores decreased significantly from a baseline of 6.8 to 0.9, 0.6, and 0.8 at 15 minutes, 2 hours, and 24 hours after procedure, respectively (Figure 4).

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The mean pain numeric rating scale at baseline and 15 minutes, 2 hours, and 24 hours after treatment, showing significant and sustained reduction in pain intensity.

Regarding PGIC, the majority of patients (98.1% at 2 hours, 98.1% at 24 hours) reported feeling very good or good (Figure 5). Only one patient reported “no change” in PGIC scale at 2 hours, but “very good” at 24 hours, and another patient rated her PGIC as “good” at 2 hours and “poor” at 24 hours due to return of headache which was slightly worse than before.

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Patient global impression of change after the procedure at 2 hours and 24 hours. The majority of patients rated the treatment result as very good or good.  PATIENTS SIMILARLY RATE RELIEF FROM TRANS-NASAL COTTON-TIPPED CATHETERS VERY HIGH.

Overall, the procedure was well-tolerated. Adverse events reported by the study population were mild (Figure 6), including transient throat numbness (100%), nausea (10.9%), dizziness (10.9%), vomiting (1.8%), nasal discomfort (18.2%), and worsening of preexisting headache (1.8%). These adverse events were transient and lasted less than 24 hours.  I RARELY SEE ADVERSE REACTIONS THOUGH THERE IS LIMITED COMPLAINTS ABOUT TASTE AND THROAT NUMBNESS BUT BECAUSE OF THE SLOWER DELIVERY THIS IS LESS OF A PROBLEM.  CHIEF COMPLAINT IS NASAL DISCOMFORT THAT CAN USUALLY BE ELIMINATED WITH AFRIN NASAL SPRAY AND LIDOCAINE SPRAY. THOSE SPRAYS.

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Adverse events recorded in the first 24 hours after the procedure.

5. Discussion

This retrospective case series demonstrated that transnasal SPG block with 2% lidocaine, using the Sphenocath device, is an effective and safe treatment for acute migraine headaches. There was a rapid relief of headaches observed at 15 minutes and 2 hours, and treatment effect was sustained at 24 hours after procedure in most patients. 70.9%, 78.2%, and 70.9% of patients were completely headache-free at 15 minutes, 2 hours, and 24 hours, respectively, while further 27%, 20%, and 27% achieved 50% or more headache relief at 15 minutes, 2 hours, and 24 hours, respectively. The majority of study population reported either very good or good response on PGIC at 2 hours and 24 hours.

A number of studies were published over the years regarding SPG blockade in acute migraine, with variable results []. Kudrow et al. [] conducted a noncontrolled study in migraine patients using 4% intranasal lidocaine and showed that 12 out of 23 patients achieved complete headache relief, and the effect was sustained at 24 hours. Maizels and Geiger [] evaluated the efficacy of 4% intranasal lidocaine as a treatment for acute migraine attacks, which was administered by the patient at home, in a double-blind, randomized controlled study. There was a significant reduction in headache severity at 15 minutes compared to placebo, but there was headache recurrence in 21% of patients receiving lidocaine.

Another placebo-controlled study compared outcomes for acute treatment of chronic migraine patients with intranasal 0.5% bupivacaine (n = 26) or saline (n = 12) using the Tx 360® device to block the SPG []. The injection was given twice a week for 6 weeks. The trial revealed significant reduction in pain numeric rating scores in the bupivacaine group at 15 minutes, 30 minutes, and 24 hours after each treatment. A randomized, double-blind, placebo-controlled study using intranasal bupivacaine or saline injections in patients presenting to the emergency department with acute frontal-based headache [specific classification was not required] demonstrated no significant difference in the proportion of patients achieving 50% or more headache relief at 15 minutes [].

Other studies used different agents for SPG blockade. For example, Bratbak et al. used onabotulinum toxin A injections into the SPG in 10 patients with intractable chronic migraine in an open, uncontrolled study []. This was done through a percutaneous infrazygomatic approach with a novel injection device. A statistically significant reduction of moderate and severe headaches was observed at 2 months after treatment; there were a total of 25 adverse events, mostly local discomfort, but none were classified as severe.

The SPG unique position in the PPF, as well as its multiple neural connections to sensory and autonomic systems involved in pain generation and propagation and the associated autonomic manifestations seen in many primary headache and facial pain syndromes, makes it a promising target for the treatment of these conditions. Inhibition of parasympathetic outflow from the SPG causes reduced activation of perivascular pain receptors in the cranial and meningeal blood vessels, with resultant reduction in the release of neuroinflammatory mediators (acetylcholine, nitric oxide, vasoactive intestinal peptide, substance P, and calcitonin gene-related peptide) from sensory fibers supplying the cranial and meningeal vasculature. This, in turn, reduces pain intensity and intracranial hypersensitivity observed in migraine [].

In our study, SPG blockade produced a rapid relief of headache at 15 minutes, with a significant treatment effect observed at 24 hours and high patient satisfaction. In general, the treatment was well-tolerated. We recorded few adverse events, which were mild and transient, similar to those seen in previous studies [].

The main limitation of our study included the lack of a placebo group, as subjective pain response might have a significant placebo component []. However, the high treatment response and satisfaction rates in this study were both encouraging and clinically meaningful for our patients. We did not assess the use of analgesics after two hours of receiving the SPG block, which might have influenced the headache relief percentage at 24 hours. However, this is allowed in acute headache trials guidelines [].

6. Conclusion

Transnasal SPG blockade is emerging as an effective and safe option for the treatment of several disabling headache and facial pain conditions such as migraine, cluster headache, and trigeminal neuralgia. Its ease of administration using noninvasive devices, safety profile, and quick pain relief makes it an attractive treatment option for these conditions. More well-designed studies are needed to further explore the efficacy of this treatment modality and its use as part of a comprehensive headache management program.

Conflicts of Interest

The authors report no conflicts of interest related to this paper.

References

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9. Khan S., Schoenen J., Ashina M. Sphenopalatine ganglion neuromodulation in migraine: What is the rationale? 2014;34(5):382–391. doi: 10.1177/0333102413512032. [PubMed] [Cross Ref]
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11. Piagkou M. N., Demesticha T., Troupis T., et al. The Pterygopalatine Ganglion and its Role in Various Pain Syndromes: From Anatomy to Clinical Practice. 2012;12(5):399–412. doi: 10.1111/j.1533-2500.2011.00507.x. [PubMed][Cross Ref]
12. Láinez M. J. A., Puche M., Garcia A., Gascón F. Sphenopalatine ganglion stimulation for the treatment of cluster headache. 2014;7(3):162–168. doi: 10.1177/1756285613510961. [PMC free article] [PubMed] [Cross Ref]
13. Suzuki N., Hardebo J. E. The cerebrovascular parasympathetic innervation. 1993;5(1):33–46. [PubMed]
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17. Coven I., Dayısoylu E. H. Evaluation of sphenopalatine ganglion blockade via intra oral route for the management of atypical trigeminal neuralgia. 2016;5(1, article no. 906):1–5. doi: 10.1186/s40064-016-2612-8. [PMC free article][PubMed] [Cross Ref]
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19. Candido K. D., Massey S. T., Sauer R., Darabad R. R., Knezevic N. N. A novel revision to the classical transnasal topical sphenopalatine ganglion block for the treatment of headache and facial pain. 2013;16(6):E769–E778. [PubMed]
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24. Cady R., Saper J., Dexter K., Manley H. R. A double-blind, placebo-controlled study of repetitive transnasal sphenopalatine ganglion blockade with Tx360® as acute treatment for chronic migraine. 2015;55(1):101–116. doi: 10.1111/head.12458. [PMC free article] [PubMed] [Cross Ref]
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Dr Shapira Awarded Diplomate Status with American Board of Sleep and Breathing. Currently in Boston Learning Advance Pain Management at Harvard Medical School.

Dr. Shapira Blog, Lake Forest, Sleep, TMJ 1 Comment

I am pleased to announce that I am now a new Diplomate of the American Board of Sleep and Breathing. I am a long term Diplomate of the American Board of Dental Sleep Medicine, Credentialed by the Sleep Disorder Dental Society (SDDS) and a Founding member of both the SDDS (Now AADSM) and Dosa , the Dental Organization for Sleep Apnea.

I did research into jaw position and sleep apnea as a visiting Assistant Professor at Rush Medical School from 1985 until 1991 and returned as an Assistant Professor from 1998 until 2001.  I had the pleasure of  working with Dr Rosalind Cartwright who was responsible for the growth of Dental Sleep Medicine.

I am currently in day two of my Harvard Medical School course on Advanced Pain Management. I am spending all of this week in Boston to improve on my skills in pain management.

The program is on Advanced Pain Management continuing Education with Academy of Integrative Pain Management and Harvard Medical School’s Top Pain Doctors.

Updates and Practice Recommendations to
Optimize the Assessment and Treatment of Pain
Headache, Fibromyalgia, Neuropathic, Myofascial, Cancer, Abdominal, Pelvic, Musculoskeletal, Spinal Pain.

https://americansleepandbreathingacademy.com/

Chicago: Learn How to Self-Administer Sphenopalatine Ganglion Blocks

Dr. Shapira Blog, Chicago, Uncategorized 6 Comments

In 1986 I learned about Sphenopalatine Ganglion Blocks from a patient who brought me the book, “Miracles on Park Avenue” and wanted me to find him a doctor who did the procedure in Chicago. I was amazed when I read the book and was dismayed when I could not find anyone in the Chicago area who did the procedure.

I learned the procedure from Dr Jack Haden in Kansas city that same year and I have used it ever since. Initially I did a lot of intra-oral injections through the greater palatine foramen because it was a “comfortable” injection for me to give in an area I routinely gave anesthetic. Later, I learned techniques for extra-oral injections which were initially outside my comfort zone. I have embraced them over the years for their ease and predictability.  My Blog at www.SphenoPalatineGanglionBlocks.com has a wide range of information about Sphenopalatine Ganglion Block including indications and history of this “Miracle Block”.

I also took a while to be comfortable with doing the trans-nasal block because it was outside my aera of comfort. I have done thousands of these over the years and have adapted my techniques. In the beginning I always brought the patients in to my office for me to do the SPG blocks.

I have always had long-distance patients who traveled to see me for TMJ treatment and neuromuscular treatment and UI would teach my patients how to treat and eliminate their pain between visits with Travell Spray and Stretch techniques. This was life-changing for my patients who could now turn off severe head, neck and facial pain as well as migraine without a trip to my office. This was initially difficult because pharmacies did not understand the prescriptions and vapocoolant spray was often hard for patients to buy.

Over time, it became routine for me to automatically offer this to all patients. I would also teach them the basic principles so they could relieve pain anywhere in their body.

Empowering patients to take control of their pain without prescription medications resulted in better patient care, fewer visits both to my office and to other physicians and emergency rooms in hospitals.

I later began utilizing home ULF-TENS (Myomonitor) units to my patients for home use rather than just in my office and againfound a tremendous improvement in my ability to care for my patients and in their quality of life.  The Myomonitor also acts as an at home on demand Neuromodulation device for the Sphenopalatine Ganglion.  The Myomonito has over a 50 year safety record.

Every time I empowered patients to self-care I was rewarded with great patient appreciation for my efforts. The same level of pain relief with fewer doctor visits improved the quality of thei lives. Truth is, “Quality of Life Sucks when you are in a Doctor’s office or waiting in an ER.

Success rates for treatment improved with fewer visits and lower costs.  This link is to videos of patients who have experienced SPG Blocks.  https://www.youtube.com/playlist?list=PL5ERlVdJLdtlk8PbufsI0l_MzHo4oOb6g

I used the Sphenopalatine Ganglion Block initially only as a measure of last resort, when other treatments were not working well. My patients who received SPG Blocks taught me that they did better when I did the blocks and the number of visits decreased while their quality of life increased. I remember when I first began to teach patients how to self-administer it was with great trepidation and I did blocks twice a day in the office for two days before teaching them to self-administer because I was worried about adverse reaction, even though they never occurred. Twice a day administration drastically improved the positive effects of the blocks as the blocks appeared to have a cumulative action and increased exposure in frequency and duration increased effectiveness.

I no longer reserved these for patients with TMJ and Facial pain but began to use them for Anxiety, depression and for problems like dental phobias and that were either difficult to treat or resistant to treatment. Gradually, I began to teach self administration to all my patients and found they appreciated having control.

Recently several devices have received FDA approval for delivering anesthetic to the area of mucosa overlying the Sphenopalatine Ganglion and physicians began to bring patients in for a series of 10 treatments (every two weeks) for $750.00 per treatment or $7500 for a course of treatment. (Blue Cross / Blue Shield recently stopped paying for these blocks calling them experimental but in reality I think they became too expensive) These devices are the Sphenocath, the Allevio and the TX 360. All devices are expensive and a single use device costs a physician about $75.00.

When I teach patients to self-administer SPG Blocks I no longer use the cotton-tipped applicators but have switched to cotton-tipped catheters that supply continual capillary feed to the mucosa over the Sphenopalatine Ganglion. This has, in my opinion increased the effectiveness far beyond any of the commercial catheters.

The Sphenocath, the Allevio and the TX 360 are all basically “squirt guns” that shoot a small amount of anesthetic over the mucosa covering the Sphenopalatine Ganglion. Ideally patients will remain supine for 10-20 minutes to increase absorption time.

The cotton-tipped catheter in contrast delivers a continual flow of anesthetic to the mucosa and can be kept in place for 20 minutes to several hours and can be refilled as needed. Due to the continual flow there is no reason to stay supine (on back) but with acute severe pain an initial supine position may increse speed of onset. The size of the cotton-tipped nasal catheter is larger than the other devices and there is certainly cases where I use a Sphenocath or TX360 in my practice. If I teach self-administration I have my patients use the Sphenocath because it is reusable at home. The TX360 can esily be utilized for self administration but is a single use device only.

The cost to the patient of doing a bilateral SPG block with cotton-tipped nasal catheters after initial appointments is less than $1.00. This is an enormous cost saving to the patient and to insurance companies and makes it far less expensive than almost any of the prescription medications available for treating migraine and chronic daily headaches.

In addition there are virtually no side effects from medication. I generally use 2% lidocaine that is extremely safe and has anti-inflammatory properties.

The biggest savings is in time and medical expenses as patient no longer have to leave work for medical visits or suffer long ER waits and thousands of dollars of expense. The biggest savings is TIME. It is the one thing that if we spend it we can never get it back.

I usually will start the self-administration protocol as twice daily for multiple reasons. The two main reasons is it offers better immediate control of even severe pain and secondly if a patient is doing it twice daily they rapidly develop a high level of expertise and can do it without problems in the future. In patients with tight nasal passages they tend to become easier to navigate over time with repeated applications.

I have taught patients from across the United States as well as International patients how to Self-Administer Sphenopalatine Ganglion Blocks.

This link is to over 100 videos of patients treated with Neuromuscular Dentistry, Trigger Point Injections, Sleep Apnea Appliances and SPG Blocks: https://www.youtube.com/channel/UCk9Bfz6pklC7_UluWFHzLrg/videos

I used to use SPG Blocks only for patients with the most difficult problems, I was wrong.  I now believe it should be part of the diagnostic work-up for all headache patients before they receive medications and injections like BOTOX.

Chicago Metropolitan area has three airports: O’hare Airport, Midway Airport and Mitchell Field just south of Milwaukee.  O’hare and Mitchell are the most convenient to my office.  The office is also located on the North Line of Metra (Union Pacific to Kenosha) at the Fors Sheridan Train Station.

Pain Is Destroying My Life! Pain Solutions Restore Your Quality Of Life.

Dr. Shapira Blog, Chicago, Chronic Daily Headache, Clicking & Popping, Cluster Headache, GURNEE OROFACIAL PAIN, Headaches and Migraines, SPG Block Anxiety, SPG Block Cluster Headache, SPG Block Migraine, SPG blocks, Sphenopalatine Ganglion Blocks, TMJ affects your posture, TMJ ARTHRITIS, TMJ Causes Stress, TMJ Dentist, TMJ Migraines, TMJ Neck & Back Pain, TMJ Numbness in Arms & Fingers, Uncategorized 0 Comments

Living day to day with severe or chronic pain can be agonizing to your spirit, your family and your life.

There is hope for patients with chronic head, neck, face and back pain.

Millions are disabled with chronic pain. It i estimated that 100 million Americans have chronic pain and as many as 11 million are disabled by chronic headaches and migraines.

Just outside Chicago in Highland Park is a small office dedicated to giving patients their lives back by freeing them from their painful prisons. Dr Shapira utilizes SPG (SphenoPalatine Ganglion) Blocks that were featured in the book “Miracles on Park Avenue” and was the story of Dr Milton Reder a New York ENT who saw thousands of patients from around the world seeking pain relief.

Dr Shapira has over 100 patient testimonials on his YouTube channel.

https://www.youtube.com/channel/UCk9Bfz6pklC7_UluWFHzLrg/videos

Many of the testimonials are from physicians or dentists who have taken Dr Shapira’s courses on techniques for utilizing these “Miracle” blocks.

Each and every patient is unique and different methods of giving the blocks are important to some patients. Self-Administration is the ideal method according to Dr Shapira because it frees the patient from trips to doctors offices and emergency rooms and gives them immediate access as needed.

The Sphenopalatine Ganglion is the largest Parasympthetic Ganglia of the head and lies in the Pterygopalatine fossa behind the palate and is attached to the maxillary division of the trigeminal nerve.

SPG Blocks are especially effective for chronic headaches, migraines, cluster headaches and other Trigeminal autonomiccephalgias because of its control of the autonomic nervous system of the head and throughout the body. Sympathetic fibers from the cervical ganglion chain also pass through the ganglion and travel along the course of the Trigeminal Nerve.

The Trigeminal nerve is the primary driver of all headaches and migraines but it is most commonly known as “The Dentist’s Nerve” If you suffer headaches, blame the trigeminal nerve and the autonomic nerves that travel down its fibers. https://www.sleepandhealth.com/disorders-and-treatments/

We are all familiar with trips to the dentist where we receive anesthetics for dental work and know the feeling of numbness when we leave. What many of us are not aware of is the the Trigeminal Nerve is actually part of the brain as are the other 11 cranial nerves.

The Trigeminal Nerve or fifth cranial nerve goes to the teeth, the jaw bones, the jaw joints or TMJ (TM Joints), the jaw muscles, the periodontal ligaments, the gingiva and mucosal surfaces of the mouth (the gums), the anterior 2/3 of the tongue. ENT’s are also extremely familiar because it goes to the mucosa of the nose and sinus linings and is responsible for sinus pain and sinus headaches as well. Many patients have hearing problems related to the Trigeminal nerve because it innervates the tensor muscle of the ear drum (Tympanic membrane) or Tensor Veli Tympani. It also controls the opening and closing of the eustacian tube thru the Tensor Veli Palatini muscle. This is the muscle that prevents food and liquids from entering the nose.

There are three branches of the trigeminal Nerve. The mandibular Branch and the maxillary branch are where Dentists are the acknowledged experts. The opthalmic branch is often thought of belonging to the opthamologists and facial surgeons but in truth dentists are primarily responsible for input to this part of the trigeminal nerve as well. Retro-orbital pain and the lower eyelid are controlled by the maxillary branch while the upper eyelid and forehead is the opthalmic branch.

Control of nociception into Trigeminal Nerve is the ideal method of reducing or eliminating headaches and migraines. The Sphenopalatine Ganglion is a tool to control the autonomic aspects of the Trigeminal Nerve.

The largest input to the brain is thru the proprioceptive aspects of the Trigeminal nerve that pass thru the mesencephalic nucleus of the brain. This is where Neuromuscular Dentistry becomes invaluable to correcting and eliminating long term chronic head and neck pain. While SPG Blocks address the autonomic nervous system neuromuscular dentistry addresses the Somato-Sensory nervous system that controls muscle function and posture. Myofascial Pain is the most common cause of pain anyhere in the body.

The Trigeminal nerve accounts for over 50% of all input to the brain after amplification in the Reticular Activating System. The Reticular Activating System is part of the Limbic (emotional Center of Brain) System and connects to the Hypothalamus-Pituitary-Adrenal complex. This is also where we experience anxiety, depression and symptoms form stress overload. SPG Blocks can eliminate many of those feelings.

Stress overload causes us to move into Sympathetic Overload and is frequently responsible for Sympathetically Maintained Pain seen in CRPS or Chronic Regional Pain Syndrome, previously called causalgia and RSD or Reflex Sympathetic Dystrophy. SPG Blocks help our bodies and mind reset from Sympathetic Overload and the “Fight or Flight reflex” and turns on the parasympathetic “Feed and Breed reflex” where we experience feelings such as well being and love. It invokes the feelings we have playing with puppies or babies, just the opposite of “being stressed out”.
“…

Chicago Cluster Headache: Treatment and Prevention: Are Sphenopalatine Ganglion Blocks The Answer?

Dr. Shapira Anxiety, autonomic cephalgias, Blog, Chronic Daily Headache, Cluster Headache, Headaches and Migraines, Physiologic Dentistry, TMJ, Uncategorized 0 Comments

Are Spenopalatine Ganglion Blocks Superior to standard drug regimens?
Cluster Headache treatment can be divided into treatment of acute attacks and prevention and treatment should also be divided.

Sphenopalatyine Ganglion Block Testimonials:

Cluster headaches common symptoms include:
Sudden onset of pain,Frequently behind the eye (retro-orbital) and around the eye (periorbital)
Pain rapidly builds to a peak intensity over 10 to 15 minutes
Restlessness or agitation
Nasal congestion or fullness
Eyelid drooping (ptosis) or swelling
Red, swollen or watery eyes
Sweating of the head and neck

They are more common in males and typically begin in late 20’s to early thirties.

They are one of a group of disorders known as Trigeminal Autonomic Cephalgias. They have in common that they are autonomic in orgin and are mediated by the Trigeminal Nervous System.

The Sphenopalatine Ganglion also known as Meckel’s Ganglion or the PterygoPalatine Ganglion is the largest Parasympathetic ganglion of the head whick also includes sympathetic fibers and Trigeminal nerves that pass though it without synapse.

I have previously written on how SPG Blocks have successfully treated and prevented SUNCT (short-lasting unilateral neuralgiform headache with conjunctival injection and tearing) in conjunction with a physiologic orthotic to eliminate noxious input th the Trigeminal nervous system.

Another Trigeminal Autonomic Cephalgia is the Paroxysmal Hemicrania that an article in Curr Pain Headache Rep. 2014 Apr;18(4):407. doi: 10.1007/s11916-014-0407-6. The article discusses how Greater Occipital Nerve blocks and Sphenopalatine Ganglion Blocks can treat these headaches.

The mainstay of treatment for Cluster Headaches for many years has been Oxygen administration that frequently stops acute attacks, it is safe and frequently effective. Triptans are also frequently utilized for both acute attacks and as a preventive measure.

Verampamil, a Calcium Channel Blocker and Lithium have been shown to be effective for many patients in preventing attacks.

A recent article in Curr Neuropharmacol. 2015;13(3):304-23 titled “The Neuropharmacology of Cluster Headache and other Trigeminal Autonomic Cephalalgias.” does a review of most current treatments for acure attacks and prevention. (the entire PubMed abstract is copied below). It also discusses new methods of treatment such as neurostimulation.

Almost 100% of all headaches are mediated by the Trigeminal Nervous System. The TrigeminoCervical complex is primarily responsible for cervical and occipital headaches and the TrigeminoVascular System seem to be the primary for release of neurotransmitters and neuropeptides that cause vasodilation . CGRP or Calcitonin Gene Related Peptide is one of these that research is currently investigating.

Unfortunately some of the most effective treatments due not create windfall profits for drug companies and therefore do not receive significant funding for research.

The amazing results frequently seen by altering noxious neural input to the Trigeminal nerve with neuromusculr orthotics are left unfunded by both drug companies and the NIH.
The Sphenopalatine Ganglion Block has recently received more intrest as companies investigate the viability onf implantable stimulators of the Sphenopalatine Ganglion.

New devices are also coming on the market to do SPG Blocks including the Sphenocath, the TX 360 and the MIRx Treatment Protocols and the Allevio device.

The injections continue to be highly effective but the self administration with cotton tipped applicators is, by far, the most cost effective method and more importantly it gives patients the ability to use SPG Blocks as preventives and for acute treatment.

I teach courses to physicians and dentists it giving SPG Blocks and I routinely teach my patients to self administer blocks intranasally.

Curr Neuropharmacol. 2015;13(3):304-23.
The Neuropharmacology of Cluster Headache and other Trigeminal Autonomic Cephalalgias.
Costa A1, Antonaci F, Ramusino MC, Nappi G.
Author information
1National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, via Mondino 2, 27100 Pavia, Italy. alfredo.costa@mondino.it.
Abstract
Trigeminal autonomic cephalalgias (TACs) are a group of primary headaches including cluster headache (CH), paroxysmal hemicrania (PH) and short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT). Another form, hemicrania continua (HC), is also included this group due to its clinical and pathophysiological similarities. CH is the most common of these syndromes, the others being infrequent in the general population. The pathophysiology of the TACs has been partly elucidated by a number of recent neuroimaging studies, which implicate brain regions associated with nociception (pain matrix). In addition, the hypothalamic activation observed in the course of TAC attacks and the observed efficacy of hypothalamic neurostimulation in CH patients suggest that the hypothalamus is another key structure. Hypothalamic activation may indeed be involved in attack initiation, but it may also lead to a condition of central facilitation underlying the recurrence of pain episodes. The TACs share many pathophysiological features, but are characterised by differences in attack duration and frequency, and to some extent treatment response. Although alternative strategies for the TACs, especially CH, are now emerging (such as neurostimulation techniques), this review focuses on the available pharmacological treatments complying with the most recent guidelines. We discuss the clinical efficacy and tolerability of the currently used drugs. Due to the low frequency of most TACs, few randomised controlled trials have been conducted. The therapies of choice in CH continue to be the triptans and oxygen for acute treatment, and verapamil and lithium for prevention, but promising results have recently been obtained with novel modes of administration of the triptans and other agents, and several other treatments are currently under study. Indomethacin is extremely effective in PH and HC, while antiepileptic drugs (especially lamotrigine) appear to be increasingly useful in SUNCT. We highlight the need for appropriate studies investigating treatments for these rare, but lifelong and disabling conditions.

Curr Pain Headache Rep. 2014 Apr;18(4):407. doi: 10.1007/s11916-014-0407-6.
Paroxysmal hemicrania: an update.
Prakash S1, Patell R.
Author information
Abstract
Paroxysmal hemicrania (PH) is an underreported and underdiagnosed primary headache disorder. It usually begins in the third or fourth decade of life. The recent observations indicate that it is equally prevalent in both males and females. PH is characterized by severe, strictly unilateral head pain attacks that occur in association with ipsilateral autonomic features. The attacks in PH are shorter and more frequent compared with cluster headache (CH) but otherwise PH and CH have similar clinical features. The hallmark of PH is the absolute cessation of the headache with indomethacin. However, a range of drugs may show partial to complete relief in certain groups of patients. Neuromodulatory procedures, such as greater occipital nerve blockade, blockade of sphenopalatine ganglion and neurostimulation of the posterior hypothalamus, are reserved for refractory PH.…

Effective Migraine Relief: The Sphenopalatine Ganglion Block

Dr. Shapira Blog 2 Comments

Elimination and Treatment of Severe Migraines with SPG Block

The SPG Block can not only treat migraines but can also prevent and/or eliminate migraines providing a cure for some migraine patients.

The Sphenopalatine Ganglion is the largest Parasympathetic Ganglion of the head and is linked to the Trigeminal Nervous System.

The Trigeminal nervous system is responsible for almost 100% of all migraines and other headaches.

Migraine medications generally act to counter the effects of neuropeptides that are released by the Trigemino-Vascular System that cause vasodilation and leads to migraines.

The Trigemino-Cervical Complex is also a significant cause of headaches , especially occipital headaches and other upper cervical related headaches. Physiologic Dentistry is so effective at treating migraines and other headaches by it’s action of reducing noxious input to the trigeminal nervous system. This changes the patters of neurotransmitter and neuropeptide release.

Combining Physiologic Dentistry with SPG Blocks can give additive effects.

The SPG Block has been called the “Miracle Migraine Cure” but it is not always successful. When it is successful it works by blocking the “Flight or Fight” response which is a Sympathetic Overload often associated with high stress.

The most effective type of SPG Block is the injection directy to the pterygopalatine fascia. The intraoral injection via the Greater Palatime foramen is also extremely effective.

Less invasive methods have been marketed more recently where anaesthetic is delivered via a nasal catheter. The three brands are the Sphenocath, the Allevio and the TX360.

In my opinion the Sphenocath is the best of this group. I recently taught approximately 100 physiologic dentists at the ICCMO meeting how to preform SPG Blocks. I chose the Sphenocath device for that course as the easies and most accurate to administer.

My favorite method of doing SPG Blocks is with hollow cotton tipped applicators because they are easy but more important patients can easily learn to self administer them. They can do them to prophylacticaly to prevent headaches and migraines or to turn them off.

Unlike medications they are very safe and effective and can be done for less that a dollar/ day.

Side effects include lowering blood pressure (safely), reducing anxiety, producing a calm state and letting patients dop into a parasympathetic mode.

The Autonomic nervous system includes both sympathetic and parasympathetic components. Sympathetic system is preparing for battle, high stress and parasympathetic system is sleep, rest, digestion, calm, sexual response, love, family, etc.

SPG blocks have been reported to treat the following conditions:
Migraine
Cluster headache
Chronic Daily Headaches
Trigeminal neuralgia
SUNCT
Herpes zoster
Paroxysmal hemicrania
Cancer of the head or neck
Facial pain that is atypical
Complex regional pain syndrome (CRPS)
Temporomandibular disorder
Fibromyalgia
Arthritis Pain
Menstrual Cramps
TMJ
MPD
Nasal contact point headache
Vasomotor rhinitis
Anxiety
Depression

The book”Miracles on Park Avenue’ was written about an ENT in New York City whose entire practice was treating all types of disorders with Sphenopalatine Ganglion Blocks.

I originally started using the block in the late 1980’s after a patient came in with a copy of the book and asked me to find him a doctor in Chicago who utilized this technique.

There was no one in Chicago but a friend and mentor Dr Jack Haden in Kansas City did the technique so I visited Jack and learned how to administer SPG Blocks.…

Pain Management in Chicago: The best approach is pain elimination be correcting physilogical causes of pain.

Dr. Shapira Blog 0 Comments

Managing Pain vs Pain Elimination:

The American Academy of Pain Management is the largest group of health care providers specifically dedicated to managing pain.  I am a long term Diplomate of that group but have always had problems with pain management rather than pain elimination being the primary focus of that group.  The beauty of physiologic treatment is it’s focus on eliminating the underlying causes of pain rather than focusing on managing of pain. I expect and routinely  “cure” my patients while physicians expect to manage their patients pain.  The dichotomy of treating the symptom or eliminating the underlying origins of pain is a very different universe.  I have always found it difficult to accept incomplete pain relief as anything other than failure though in actuality 50, 60, or  70 percent pain relief can be a huge success for patients.

Eliminating pain by correction of the underlying causes is always better than managing pain with medications. This is especially true of head and neck pain, facial pain and migraines.

The Trigeminal Nerve is the at the root of all headaches and migraines. Pain management typically involves medications directed at the Neurotransmitters released by the Trigeminal Nervous System and the Trigemino-Vascular System.

Neurotransmitters are responsible for the transmission of nerve impulses from one neuron to the next. While medications can effect the balance of chemicals in the brain the most effective method of eliminating pain is by changing the neural input so the balance of neurotransmitters and neuropeptides in the brain is in physiological balance for pain prevention.

Physiologic Dentistry is the best method of reducing noxious input to the CNS through the Trigeminal Nerve.

The goal is not just pain reduction or pain management but elimination of pain through creation of healthy physiologic state and correction of patterns of neurotransmitter release, ie correction of the underlying chemical imbalances by correction of neural input patterns.

According to Wikipedia “Neurotransmitters are endogenous chemicals that enable neurotransmission. They transmit signals across a chemical synapse, such as in a physiologic junction, from one neuron (nerve cell) to another “target” neuron, muscle cell, or gland cell.[1] Neurotransmitters are released from synaptic vesicles in synapses into the synaptic cleft, where they are received by receptors on other synapses. Many neurotransmitters are synthesized from simple and plentiful precursors such as amino acids, which are readily available from the diet and only require a small number of biosynthetic steps to convert them. Neurotransmitters play a major role in shaping everyday life and functions. Their exact numbers are unknown but more than 100 chemical messengers have been identified”

 

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