PALM SPRINGS, California — A noninvasive, easy-to-administer sphenopalatine ganglion block relieves postdural puncture headache (PDPH) faster than an epidural blood patch in obstetric patients and has fewer adverse effects, new research shows.The block works so well in patients with PDPH that it should the considered the first line treatment in this population, said Preet Patel, MD, Department of Anesthesiology & Pain Management, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey. Dr Patel presented the research here during the American Academy of Pain Medicine (AAPM) 2016 Annual Meeting.
PDPH, which can be caused when the dura is accidentally punctured during administration of an epidural analgesic, can be very debilitating, said Dr Patel. “It’s a postural headache, so patients are not able to get out of bed; the headache gets worse when they sit upright or try standing up.” The headache typically resolves within 2 weeks, “but anything we can do” to alleviate the pain before that would improve patient satisfaction, he said.
A PDPH is typically treated with an epidural blood patch. Blood is usually drawn from the patient’s arm and injected into the spine, where it clots and seals the puncture. These blood patches do work, ranging from 61% to 90% effective. “Most clinicians would agree that the blood patch is very effective” in treating PDPH, he said. However, because the blood patch involves an invasive procedure, serious complications, including motor and sensory defects, meningitis, seizure, hearing loss, and subdural hematoma, can and do occur on rare occasions.
Novel Application
The sphenopalatine ganglion block has been used successfully for other headaches, including migraines, for more than 100 years, without significant side effects. What the research team is proposing now is “a novel application,” said Dr Patel. The procedure his team uses is minimally invasive and carried out at the bedside without using imaging. “It’s quite simple to do,” said Dr Patel, and takes about 20 minutes. The procedure involves placing two 6-inch, cotton-tipped, hollow plastic applicators bilaterally into each nasal passage, placing the applicator superior to the middle nasal turbinate, and injecting 0.5 to 1.5 mL of 4% lidocaine on each side. For the retrospective study, researchers reviewed the records of 72 patients without a history of primary headaches who had experienced PDPH from an epidural needle. Group 1 (n = 33) received the block, although the blood patch was available upon request. Group 2 (n = 39) had routine blood patch. At 30 minutes and 60 minutes after the procedure, the block was more effective than the blood patch in terms of headache remittance. In group 1, 18 patients (54.5%) recovered from the headache at 30 minutes, while in group 2, only 8 (20.5%) recovered at 30 minutes (P = 2.73 × 10–3). At 60 minutes, 21 (63.6%) in group 1 recovered compared to 12 (30.7%) (P = 5.29 × 10–3). At 24 and 48 hours and at 1 week, the nerve block was as effective as the blood patch. “We were able to show that the block works much faster than the blood patch in relieving the headaches,” said Dr Patel. “So it works more quickly and as effectively when you look at it over the long- term.” In group 2, there were a total of nine emergency department (ED) visits, three cases of radiating backache, one vasovagal reaction, and one case of temporary hearing loss. No group 1 patients had to visit the ED, and no complications or adverse effects occurred. Although there are generally no adverse effects associated with the block, patients sometimes do have a bitter taste at the back of the mouth, said Dr Patel. Most women with PDPH aren’t discharged home until the headache is resolved. “Often patients who receive the block are able to go home the same day, or the very next day because the headache resolves so quickly,” commented Dr Patel. He suggested that if the block doesn’t work the first time, it should be repeated because the ganglion may have been missed the first time. “We advocate that you do the block and if doesn’t work, to try it a second time, and maybe even third time,” he said. “And if you have a failure at that point then you can move on to the more invasive blood patch. There really is no downside to doing the block.” The work by Dr Patel and colleagues was selected for presentation during a session on poster research highlights at the AAPM meeting. Invited to comment on the research, Lynn Webster, MD, vice president, scientific affairs, PRA Health Sciences, Raleigh, North Carolina, said this approach to treating PDPH “is news to me.” “I’ve not heard of treating spinal headaches like this before.” Because the procedure is “less invasive” and “easy to do” at the bedside, “it would be nice if it works as well as it did in their experience,” said Dr Webster. And he intends to find out. He was so impressed with this approach to treating PDPH that he’s going to try it himself. “In the research setting, we intentionally create a spinal leak and some patients will end up with a headache, so I’m going to try this and see if it works.” Dr Patel has disclosed no relevant financial relationships.
American Academy of Pain Medicine (AAPM) 2016 Annual Meeting. Poster 145. Presented February 19, 2016.
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