Medication resistant Status Migrainous (SM) is a nightmare for patients who frequently have a migraine history which evolves into continuous migraine lasting 72 hours or more.  SM is frequently resistant to over the counter and prescription abortive medications.  This article looks at the use in the Emergency Department of the use of the  Suprazygomatic approach to injecting the Sphenopalatine Ganglion or SPG.

Transnasal Sphenopalatine Ganglion Blocks can be effective but the Suprazygomatic injection has a high success rate in these cases.  The article concludes that "The SPG is known to play an integral role in the pathophysiology of facial pain and the trigeminal autonomic cephalalgias, although its exact role in the generation and maintenance of migraine headache remains unclear. Regional anesthetic suprazygomatic SPG block is potentially effective for immediate relief of SM. We believe the procedure is simple to perform and has minimal risk."

I utilize injections of the Sphenopalatine Ganglia in some patients presenting with severe pain on rare occasions in my office.  Injections to the SPG are done either intra-orally or extra-orally, and the preferred extra-oral approach is the Suprazygomatioc approach.

The article also discusses less robust response to the intra-nasal approach but this may be due to the method of administering the SPG Block.  Typically it is delivered by a commercial catheter, either the Sphenocath, the Allevio or the TX 360.  All three are essentially modified syringes that act as "squirt guns" to deliver anesthetic to the medial wall mucosa overlaying the  pterggopalatine fossa which houses the maxillary division of the Trigeminal Nerve, the maxillary artery and the Sphenopalatine Ganglion.  When delivered in this fashion ideally the patient will have one side done with patient supine and head turned to the side where anesthetic is placed for 20 -30 minutes and the repeated on the other side.  In practice both sides arre done together and often the patient does not remain supine long enough for sufficient anesthetic to pass through the mucosa.

The use of cotton-tipped swabs is also utilized by many doctors and is similar to the procedure defined by Dr Greenfiel Scluder in 1908.The original procedure used a 20% cocaine solution that passed thru the tissue more efficiently and was quite effective.

Currently, in my opinion the best trans-nasal approach is with continual capillary feed cotton-tipped catheters that continually supply anesthetic the the medial wall of the fossa and do not depend on gravity or a one time "squirt" of anesthetic.  This approach has less anesthetic flowing into the throat.  Most important is that patients can learn to Self-Administer SPG Blocks (SASPGB).  

Treatment of Status Migrainous (SM) can usually be effective with the continuous capillary delivery of anesthetic.  In the event of less than ideal relief of pain a Suprazygomatic SPG Block can be given in combination.

Future episodes can usually be prevented with prophylactic use of of SASPGB or Self-Administered SPG Blocks.

SASPGB can be utilized for a wide variety of headache and migraine disorders including Trigeminal Neuralgia.

Learn more about SPG Blocks:  https://www.ihateheadaches.org/video/anxiety-gone-for-first-time-in-life-patient-came-in-for-spg-block-for-migraine

Abstract from PubMed

Headache:  2019 Jan;59(1):69-76. doi: 10.1111/head.13390. Epub 2018 Jul 25.

The Effect of Regional Anesthetic Sphenopalatine Ganglion Block on Self-Reported Pain in Patients With Status Migrainosus

Abstract

Background: Status migrainosus (SM) is defined as a debilitating migraine attack lasting more than 72 hours in patients previously known to suffer from migraine headache. Typically, these attacks fail to respond to over the counter and abortive medications. The sphenopalatine ganglion (SPG) plays a critical role in propagating both pain and the autonomic symptoms commonly associated with migraines. SPG block via transnasal lidocaine is moderately effective in reducing migraine symptoms, but this approach is often poorly tolerated and the results are inconsistent. We proposed that an SPG block using a suprazygomatic injection approach would be a safe and effective option to abort or alleviate pain and autonomic symptoms of SM.

Methods: Through a retrospective records review, we identified patients with a well-established diagnosis of migraine, based on the International Headache Society criteria. Patients selected for study inclusion were diagnosed with SM, had failed to respond to 2 or more abortive medications, and had received a suprazygomatic SPG block. Patients had also been asked to rate their pain on a 1-10 Likert scale, both before and 30 minutes after the injection.

Results: Eighty-eight consecutive patients (20 men and 68 women) received a total of 252 suprazygomatic SPG block procedures in the outpatient headache clinic after traditional medications failed to abort their SM. At 30 minutes following the injections, there was a 67.2% (±26.6%) reduction in pain severity with a median reduction of 5 points (IQR= -6 to -3) on the Likert scale (ranging from 1 to 10). Overall, patients experienced a statistically significant reduction in pain severity (P < .0001).

Conclusion: The SPG is known to play an integral role in the pathophysiology of facial pain and the trigeminal autonomic cephalalgias, although its exact role in the generation and maintenance of migraine headache remains unclear. Regional anesthetic suprazygomatic SPG block is potentially effective for immediate relief of SM. We believe the procedure is simple to perform and has minimal risk.