This is the Pubmed abstract of Dr Shapira’s new paper on the autonomic nervous system. It explaine the effectiveness of neuromuscular dentistry iin treating all manner of head and neck pain including TMJ disorders, headache, migraine, Cluster headache and otheer disordrs related to thee trigeminal nerve.
Cranio. 2019 May;37(3):201-206. doi: 10.1080/08869634.2019.1592807.
Neuromuscular dentistry and the role of the autonomic nervous system: Sphenopalatine ganglion blocks and neuromodulation. An International College of Cranio Mandibular Orthopedics (ICCMO) position paper.
The Sphenopalatine Ganglion (SPG) is known to play an integral role in the pathophysiology of a wide variety of orofacial pains involving the jaws, sinuses, eyes and the trigeminal autonomic cephalalgias. It supplies direct parasympathetic innervation to the trigeminal and facial nerves. Sympathetic innervation from the superior sympathetic chain passes thru the SPG to the trigeminal and facial nerves.This paper reviews relevant and significant literature on SPG Blocks and Neuromodulation published in peer reviewed medical and dental journals. Neuromuscular Dentistry employs ULF-TENS to relax musculature and simultaneously provide neuromodulation to the ganglion.Conclusion: The effects of ULF-TENS on the autonomic nervous system acts on the Limbic System and Hypothalamus (H-P-A) to address Axis II issues during neuromuscular dental procedures. It also directly affects the autonomic component of the trigeminal nerve involved in almost all headaches and migraines as well as the Myofascial and Joint disorders of TMD.
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.
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.
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 [4, 5]. In addition, several studies [6–8] 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 [11, 12]. 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 .
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 [10, 12, 13]. 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 [10, 14], with the release of inflammatory mediators from blood vessels and activation of meningeal nociceptors, causing migraine pain [11, 14]. 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 [9, 10].
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 [10, 17–19].
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.
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
headache relief rate, defined as percentage of patients with 50% or more reduction in headache intensity at 15 minutes, 2 hours, and 24 hours;
change in NRS from baseline to 15 minutes, 2 hours, and 24 hours after treatment;
PGIC (effects on headache and its associated symptoms and tolerability) at 2 hours and 24 hours;
all adverse events up to 24 hours after procedure.
Statistical analysis was done using SPSS Statistics Version 23.
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.
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.
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).
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.
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.
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 .
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.
1. Marmura M. J., Silberstein S. D., Schwedt T. J. The Acute Treatment of Migraine in Adults: The American Headache Society Evidence Assessment of Migraine Pharmacotherapies. 2015;55(1):3–20. doi: 10.1111/head.12499.[PubMed][Cross Ref]
3. Becker W. J. Acute migraine treatment in adults. 2015;55(6):778–793.[PubMed]
4. Magis D., Jensen R., Schoenen J. Neurostimulation therapies for primary headache disorders. 2012;25(3):269–276. doi: 10.1097/WCO.0b013e3283532023.[PubMed][Cross Ref]
5. Lipton R. B., Munjal S., Buse D. C., Fanning K. M., Bennett A., Reed M. L. Predicting Inadequate Response to Acute Migraine Medication: Results From the American Migraine Prevalence and Prevention (AMPP) Study. 2016;56(10):1635–1648. doi: 10.1111/head.12941. [PubMed][Cross Ref]
6. Lipton R. B., Fanning K. M., Serrano D., Reed M. L., Cady R., Buse D. C. Ineffective acute treatment of episodic migraine is associated with new-onset chronic migraine. 2015;84(7):688–695. doi: 10.1212/WNL.0000000000001256.[PMC free article][PubMed][Cross Ref]
7. Lipton R. B., Silberstein S. D. Episodic and Chronic Migraine Headache: Breaking Down Barriers to Optimal Treatment and Prevention. 2015;55:103–122. doi: 10.1111/head.12505_2. [PubMed][Cross Ref]
8. Rizzoli P. B. Acute and preventive treatment of migraine. 2012;18(4):764–782. doi: 10.1212/01.CON.0000418641.45522.3b. [PubMed][Cross Ref]
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]
10. Robbins M. S., Robertson C. E., Kaplan E., et al. The Sphenopalatine Ganglion: Anatomy, Pathophysiology, and Therapeutic Targeting in Headache. 2016;56(2):240–258. doi: 10.1111/head.12729. [PubMed][Cross Ref]
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]
14. Yarnitsky D., Goor-Aryeh I., Bajwa Z. H., et al. 2003 Wolff award: possible parasympathetic contributions to peripheral and central sensitization during migraine. 2003;43(7):704–714. doi: 10.1046/j.1526-4610.2003.03127.x. [PubMed][Cross Ref]
15. Sluder G. The role of the sphenopalatine ganglion in nasal headaches. 1908;27:8–13.
16. Waldman S. D. Sphenopalatine ganglion block-80 years later. 1993;18(5):274–276. [PubMed]
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]
18. Miller S., Matharu M. Trigeminal autonomic cephalalgias: Beyond the conventional treatments. 2014;18(8, article no. 438) doi: 10.1007/s11916-014-0438-z. [PMC free article][PubMed][Cross Ref]
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]
20. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders. 2013;33(9):629–808. doi: 10.1177/0333102413485658. 3rd edition. [PubMed][Cross Ref]
21. Wasserman RA., Schack T., Moser SE., Brummett CM., Cooper W. Facial temperature changes following intranasal sphenopalatine ganglion nerve block. 2017;3(5):p. e354.
22. Kudrow L., Kudrow D. B., Sandweiss J. H. Rapid and Sustained Relief of Migraine Attacks With Intranasal Lidocaine: Preliminary Findings. 1995;35(2):79–82. doi: 10.1111/j.1526-4610.1995.hed3502079.x. [PubMed][Cross Ref]
23. Maizels M., Geiger A. M. Intranasal lidocaine for migraine: A randomized trial and open-label follow-up. 1999;39(8):543–551. doi: 10.1046/j.1526-4610.1999.3908543.x. [PubMed][Cross Ref]
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]
25. Schaffer J. T., Hunter B. R., Ball K. M., Weaver C. S. Noninvasive Sphenopalatine Ganglion Block for Acute Headache in the Emergency Department: A Randomized Placebo-Controlled Trial. 2015;65(5):503–510. doi: 10.1016/j.annemergmed.2014.12.012. [PubMed][Cross Ref]
26. Bratbak D. F., Nordgård S., Stovner L. J., et al. Pilot study of sphenopalatine injection of onabotulinumtoxinA for the treatment of intractable chronic cluster headache. 2015;36(6):503–509. doi: 10.1177/0333102415597891.[PMC free article][PubMed][Cross Ref]
27. Diener H. C., Schorn C. F., Bingel U., Dodick D. W. The importance of placebo in headache research. 2008;28(10):1003–1011. doi: 10.1111/j.1468-2982.2008.01660.x. [PubMed][Cross Ref]
28. Tfelt-Hansen P., Pascual J., Ramadan N., et al. Guidelines for controlled trials of drugs in migraine: Third edition. A guide for investigators. 2011;32(1):6–38. doi: 10.1177/0333102411417901. [PubMed][Cross Ref]
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.
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”.
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.
1National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, via Mondino 2, 27100 Pavia, Italy. email@example.com.
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.
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.…
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:
Chronic Daily Headaches
Cancer of the head or neck
Facial pain that is atypical
Complex regional pain syndrome (CRPS)
Nasal contact point headache
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.…
I have the honor and privledge of lecturing at the ICCMO meeting in San Diego. ICCMO is acknowledged as the source and fountain of knowledge about TMD, TMJ, and the Trigeminal Nervous System.
A lecture by Dr Heit and Dr Saqqur showed how the physiologic position of a physiologic appliance approved cerebral blood flow to the brain as measured by directional ultrasound.
I will be giving a lecture on the common developmental pathways of TMD, Sleep Apnea, ADD, ADHD and other chronic pain conditions.
I am also doing a short presentation followed by a hands on training in giving Sphenopalatine Ganglion Blocks by SphenoCath, Allevio and TX#^) devices, the hollow cotton tipped applicators and the intra-oral and facial approaches to Sphenopalatine Ganglion Blocks.
Iccmo Physiologic Dentists are recognized for their treatment and knowledge of trigeminal nervous system including the Trigemino-vascular system and Trigeminal cervical complex that are responsible for almost 100% of all headaches.
The sphenopalatine ganglion also known as Meckels Ganglion, the Nasal Ganglion and as the Pterygopalatine is the large parasympathetic ganglia in the head. Blocking it with Lidocaine has shown a variety of benefits in addition to treating and preventing migraines and cluster headaches.…
All migraines and headaches are products of the Trigeminal Nervous System.
It could be stated that the Trigeminal Nerve is the “MASTER OF THE UNIVERSE OF HEADACHE”
The entire universe of headaches is directly related to the Trigeminal Nervous System. One major system of the Trigeminal Nervous System is the Trigemino-vascular System. This is the system where the trigeminal nerve controls the blood flow to the anterior two thirds of the meninges of the brain. The control is asserted by release of vasoactive neuropeptides like CGRP or Calcitonin Gene Related Peptide.
CGRP is produced and released by both peripheral and central trigeminal neurons. CGRP is a potent vasodilator and when released by trigeminal nerves in the meninges it creates vasodilation. It is this vasodilation that cause migraines to be labeled vascular headaches.
MIGRAINES ARE ACTUALLY NEUROGENIC HEADACHES THAT LEAD INTO VASCULAR DILATION WORSENING AND PEAKING OF EFFECTS. THE VASODILATION IS SECONDARY NOT PRIMARY.
CGRP is produced primarily in cell bodies of motor neurons, and CGRP related to migraines is released by the trigeminal nerve.
THE TRIGEMINO-VASCULAR SYSTEM IS THE MASTER OF THE UNIVERSE OF TRIGEMINAL VASCULAR HEADACHES OR BASICALLTY ALL HEADACHES.
The Trigeminal Nerve is often called the Dentist’s Nerve because for practical purposes dentists are the Masters of the maxillary, mandibular and ophthalmic branches of the Trigeminal Nerve.
If the Trigeminal Nerve is responsible for headaches thru the Trigemino vascular system and trigeminal cervical complex then controlling the input that intiates headaches is certainly part of dentistry. Controlling the noxious input throught the trigeminal nerve responsible for setting of vascular headaches is the dentist.
The Physiologic Dentist is reccgnized experts of working with the Trigeminal nervous system to create an occlusion based on physiologic rest. Occlusion is determined ideal when function is followed by a return to physiologic rest.
It should the be fair to assert that Physiologic Dentists are the Trigeminal Nervous System Specialists including the three main branches, especially the mandibular branch that include motor neurons responsible for release of CGRP which is responsible for the vascular effects seen in migraine.
Physiologic Dentists trained to deliver Sphenopalatine Ganglion Blocks (SPG Blocks) are also Masters of The Autonomic Trigeminal Universe.
Add to this that dentists control the structures that manage airway, balance and posture as well as the Mesencephalic Nucleus the fastest synapse and only electrical synapse in the CNS. Te mesencephalic nucleus is the proprioceptive nucleus of the trigeminal nerve.
The NHLBI of the NIH has reported on “Cardiovascular and Sleep Related Consequences of TMJ Disorders”
Putting all this information together.
Dentists are the masters of the Trigeminal Nerve
Physiologic Dentists are the Masters of the masters understanding input and output to the CNS through the Trigeminal Nervous System
The trigeminal Nerve and its components the trigeminovascular system and Trigeminal cervical complex are the masters of the universe of all headaches in addition to providing key control of basic physiologic functions such as sleep and breathing.
One can only conclude the “NEUROMUSCULAR DENTISTS ARE THE MASTERS OF THE UNIVERSE FOR PREVENTING, ABORTING AND ELIMINATING MIGRAINES.”…