Emergency Room Visits and Revisits for Migraine: New Article in Nov 2017 Headache Journal

The quality of life of migraine patients is often extremely compromised. While many patients are managed effectively with medication many are not.

One measure of effectiveness of treatment would be the frequency of visits and revisits to the ER.

The best migraine treatment would make it unnecessary for patients to ever beer seen by the emergency department.

An answer for many patients may be to utilize Self-Administered Sphenopalatine Ganglion Blocks. These can be done via a safe transnasal approach which can be learned by patients.

Sphenopalatine are already utilized in ER’s for resistant migraines.According to an article (article and link below) in ALIEM (Academic Life in Emergency Medicine)
“anecdotal experience with performing SPG blocks in patients presenting to the ED with primary headaches, we have found an overwhelminging positive response, with the vast majority of patients reporting significant improvement of their symptoms.”

These same results are also possible with Self-Administration of Sphenopalatine Ganglions Blocks by the patient at home. Avoiding the ER visit can save thousands of dollars in medical expenses and create a higher level of care. Patients who have been taught to self administer can not only treat severe episodes but prevent future migraines as well. Side effects of SPG Blocks include reduction of anxiety. Self Administration of SPG Blocks can reduce lost days of work and strain on families.

Sphenopalatine Ganglion Blocks have been used in medicine since 1908 and were first described by Sluder to treat Sluder’s neuralgia now thought to be either cluster headache or TMJ disorder. SPG BLOCKS were the treatment used by Doctor Milton Reder which was turned into a book “MIRACLES ON PARK AVENUE”

There is a great deal of information available on SPG Blocks @

Many of my patients tell their stories about how SPG Blocks and other treatments work for them at:

Visit Dr Shapira’s Website: https://thinkbetterlife.com/

Neuromuscular Dentistry utilizes a Myomonitor an Ultra Low Frequency TENS that acts to stimulate the Sphenopalatine Ganglion.  NONINVASIVE SPHENOPALATINE GANGLION BLOCK FOR ACUTE HEADACHE IN EMERGENCY DEPARTMENT: A RANDOMIZED PLACEBO-CONTROLLED TRIAL. (ABSTRACT BELOW)  This study showed Bupivicaine equal to saline, not very impressive but both groups experienced over a 40% reduction in pain over 15 minutes.  The saline may have had an effect on the ganglion as well.  There was a significant reduction of headache and nausea at 24 hours.

I prefer lidocaine which passes more quickly through the tissues.  The most effective method of delivering SPG Blocks in my opinion is via transnasal catheter delivery with a continual cappilary feed through applicator tip.

 LINK to Emergency Medicine article. Trick of the Trade: Sphenopalatine Ganglion Block for Treatment of Primary Headache (article below)

Headache. 2017 Nov 2. doi: 10.1111/head.13216. [Epub ahead of print]
A Retrospective Nested Cohort Study of Emergency Department Revisits for Migraine in New York City.

Minen MT1, Boubour A2, Wahnich A3, Grudzen C4, Friedman BW5.
Author information
Migraine causes more than 1.2 million visits to US emergency departments (EDs) annually. Many of these visits are revisits among patients who had already been treated in an ED for migraine. The goal of this analysis was to determine the frequency of headache revisits among patients who present to an ED for management of migraine and sociodemographic factors associated with the revisit.
Using the New York City Department of Health and Mental Hygiene Syndromic Surveillance database, we conducted a retrospective nested cohort study. We analyzed visits from 18 NYC EDs with discharge diagnoses in the first 6 months of 2015. We conducted descriptive analyses to determine the frequency of headache revisit within 6 months of an index ED visit for migraine and the elapsed time to revisit. Using multivariable logistic regression, we assessed associations between age, sex, poverty, and revisit.
Of 1052 ED visits with an ED discharge diagnosis of migraine during the first 6 months of 2015, 277 (26.3%) had a headache revisit within 6 months of their initial migraine visit and 131 (12.5%) had two or more revisits at the same hospital. Of the revisits for headache, 9% occur within 72 hours and 46% occur within 90 days of the initial migraine visit. Sex, age, and poverty level were not associated with an ED revisit.
More than a quarter of initial ED visits for migraine are followed by headache revisits in © 2017 American Headache Society.

Trick of the Trade: Sphenopalatine Ganglion Block for Treatment of Primary Headaches
March 22nd, 2017 | Neurology, Tricks of the Trade |3 Comments
By: Jeffrey Shih, MD, RDMS and Chris Gaafary, MD
It is thought that the autonomic nervous system is likely involved in migraines and other primary headache disorders given commonly associated symptoms such as nausea, lacrimation, emesis, and rhinorrhea. The sphenopalatine ganglion (SPG) is an extracranial parasympathetic ganglion with both sensory and autonomic fibers. It has therefore been hypothesized that blockade of the sphenopalatine ganglion may produce relief from primary headaches by modulating the autonomic fibers involved in headache disorders.1

While in our anecdotal experience with SPG blocks has been overall very positive, thus far there have been only a few small studies that have investigated it’s use in the Emergency Department. The currently available evidence has been mixed.

The Literature

An small study published in JAMA showed significant benefit of intranasal lidocaine (55%) compared to a saline placebo (21%) when evaluating a primary outcome of 50% reduction in headache within 15 minutes. 2

Studies performed used targeted application of anesthetic have produced mixed results.

A study published in the Annals of Emergency Medicine showed no statistically significant difference between application of bupivacaine (48.8%) compared to a saline placebo (41.3%) when evaluating a primary outcome of 50% reduction of headache within 15 minutes. Interestingly as a secondary outcome, the bupivacaine group had reduced headache at 24 hours.3

A separate study performed in the setting of a headache clinic produced positive results showing improved relief at 15 minutes, 30 minutes, and 24 hours when comparing bupivacaine to normal saline. The primary outcome compared numeric rating scale scores between the study and control group.4 It’s important to note that both of these studies use a specialized applicator branded Tx360. It is currently unclear whether these studies received any funding from the manufacturer.


Figure 1 – The sphenopalatine ganglion is located in the pterygopalatine fossa, posterior to the middle nasal turbinate.
The Transnasal SPG Approach

There are several ways to perform an SPG block including transnasal, transoral, and lateral infratemporal approaches; however, the transnasal approach is the simplest and most practical method in the Emergency Department setting. The transnasal approach to an SPG block has the following advantages:

Quick and safe to perform
Well tolerated by patients with minimal risk of complications
Relatively non-invasive without the use of needles
Our approach uses supplies that are found in any Emergency Department.

Technique to perform an SPG block

Soak a long 10 cm cotton-tipped applicator in local anesthetic (1% to 4% lidocaine or 0.5% bupivicaine) [Fig. 2].
With the patient’s head in a sniffing position, insert the soaked cotton-tipped applicator into the naris, on the unilateral side of the patient’s headache.
Apply firm and steady pressure (similar to the insertion of nasal packing) along the superior border of the middle turbinate until you meet resistance at the posterior wall of the nasopharynx. At this point, the local anesthetic should contact the SPG and anesthetize the ganglion [Fig. 3].
Leave the cotton-tipped applicator in place for 5-10 minutes, after which the patient should experience significant improvement or resolution of their headache!

While more studies are needed before SPG blocks can be considered a standard first-line therapy for the treatment of migraines and other primary headaches, it remains a reasonable option for patients suffering from a primary headache that has been resistant to more traditional abortive treatments.

In our anecdotal experience with performing SPG blocks in patients presenting to the ED with primary headaches, we have found an overwhelminging positive response, with the vast majority of patients reporting significant improvement of their symptoms.

1. Khan S, Schoenen J, Ashina M. Sphenopalatine ganglion neuromodulation in migraine: what is the rationale? Cephalalgia. 2014;34(5):382-391. [PubMed]
2. Maizels M, Scott B, Cohen W, Chen W. Intranasal lidocaine for treatment of migraine: a randomized, double-blind, controlled trial. JAMA. 1996;276(4):319-321. [PubMed]
3. Schaffer J, Hunter B, Ball K, Weaver C. Noninvasive sphenopalatine ganglion block for acute headache in the emergency department: a randomized placebo-controlled trial. Ann Emerg Med. 2015;65(5):503-510. [PubMed]
4. Cady R, Saper J, Dexter K, Manley H. A double-blind, placebo-controlled study of repetitive transnasal sphenopalatine ganglion blockade with tx360(®) as acute treatment for chronic migraine. Headache. 2015;55(1):101-116. [PubMed]


Ann Emerg Med. 2015 May;65(5):503-10. doi: 10.1016/j.annemergmed.2014.12.012. Epub 2015 Jan 7.

Noninvasive sphenopalatine ganglion block for acute headache in the emergency department: a randomized placebo-controlled trial.



We seek to test the efficacy of noninvasive sphenopalatine ganglion block for the treatment of acute anterior headache in the emergency department (ED) using a novel noninvasive delivery device.


We conducted a randomized, double-blind, placebo-controlled trial evaluating bupivacaine anesthesia of the sphenopalatine ganglion for acute anterior or global-based headache. This study was completed in 2 large academic EDs. Bupivacaine or normal saline solution was delivered intranasally (0.3 mL per side) with the Tx360 device. Pain and nausea were measured at 0, 5, and 15 minutes by a 100-mm visual analog scale. The primary endpoint was a 50% reduction in pain at 15 minutes. Telephone follow-up assessed 24-hour pain and nausea through a 0- to 10-point verbal scale and adverse effects.


The median reported baseline pain in the bupivacaine group was 80 mm (IQR 66 mm – 93 mm) and 78.5 mm (IQR 64 mm to 91.75 mm) in the normal saline solution group. A 50% reduction in pain was achieved in 48.8% of the bupivacaine group (20/41 patients) versus 41.3% in the normal saline solution group (19/46 patients), for an absolute risk difference of 7.5% (95% confidence interval [CI] -13% to 27.1%). As a secondary outcome, at 24 hours, more patients in the bupivacaine group were headache free (24.7% difference; 95% CI 2.6% to 43.6%) and more were nausea free (16.9% difference; 95% CI 0.8% to 32.5%).


For patients with acute anterior headache, sphenopalatine ganglion block with the Tx360 device with bupivacaine did not result in a significant increase in the proportion of patients achieving a greater than or equal to 50% reduction in headache severity at 15 minutes compared with saline solution applied in the same manner.

[Indexed for MEDLINE]

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