Dr. Shapira's Chicago Headache Blog

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Wednesday, December 26, 2018

Migraines, Cluster Headaches and Tension-Type Headaches: What is Fastest and Most Effective Treatment? What is the Safest Treatment?

The pain, agony and suffering associated with headaches of all types can rapidly destroy your quality of life.   The suffering while waiting for medication to take effect can be maddening.  This is even more true when an individual has chronic severe headaches.

The most common approach of patients is to try over the counter medications that all have similar issues with slow onset and negative side effects.  Effectiveness varies and often only minimal or partial relief is obtained.

Non-steroidal anti-inflamatories  (NSAID) are probably the most common headache medication used.  This includes aspirin (Bayer), ibuprofen (Advil or Motrin), naproxen  (Allieve) and etedolac.  All of these drugs are excellent anti-inflamatories and all of them have serious side effects including GI disturbances including gastric reflux, burning, ulcers, esophageal burns, and increased bleeding times. 

 The biggest issue is not the negative and often dangerous side effects but the  lack of effectiveness and slow onset.

Tylenol or Acetaminophen is even less effective but usually does not cause GI distress but can cause permanent liver damage especially if taken with alcohol.  Again the biggest issue is poor pain relief and  the  considerable time it takes  to reach effective blood levels to treat the pain.

Pain is felt in the Limbic System where we feel emotion.  When patients are suffering severe pain their emotional level plummets. 

The National Headache Foundation recommends a Triple-Combination Medication  of acetylsalicylic acid, (aspirin), acetaminophen, and caffeine for tension-type headaches.  Unfortunately, this still requires absorption in thee GI tract and carries the same risks as the individual drugs.  Excedrin is a combination medication with these ingredients.  Excedrin and Excedrin Migraine are actually the same medication.

Compare these OTC Drugs and response time to Self-Administered Sphenopalatine Ganglion (SPG) Blocks which typically utilize 2% lidocaine, a natural anti-inflammatory that is often given to stabilize a patients heart beat but is best known  as dental anesthetic.  

Patient's can self-administer an SPG lidocaine block in minutes and relief for Migraine and Cluster Headaches can be almost immediate.  SPG Blocks are especially effective for Tension-Type Headaches and other Trigeminal Nerve associated headaches.

Sphenopalatine Ganglion Blocks can be administered in physicians offices and in Emergency Departments utilizing a nasal catheter such as a Sphenocath, Allevio or TX360.  These are all specialized catheters designed to "squirt" lidocaine to the mucosa covering the Sphenopalatine Ganglion where it sits in the pterygopalatine fossa.  The Sphenopalatine is also known as the Pteerygopalatine Ganglion, named for where it is found.

 While these "squirt gun technique" blocks are effective and can also give almost immediate relief they are also expensive and the patients life is disrupted by the headache and the need to travel for the  headache treatment.

The use of cotton-tipped nasal catheters allows the patient to self-administer SPG Blocks.  This  can be used prophylactiically to prevent headache occurrence as well as to alleviate headaches at initial onset before their increasing severity disrupt patient's lives.

Most physicians do not train patients to self-administer these blocks but it is an easily learned procedure utilized for  over 100 years.

The Sphenopalatine Ganglion is the largest Parasympathetic Ganglion of the head and is part of the Autonomic Nervous System.  The Sympathetic nerves are also part of the autonomic nervous system and are involved in the "fight or flight" reflex which is also known as the stress reflex. 

 The Sphenopalatine Ganglion is also known as the SPG, the Pterygopalatine Ganglion, the Nasal Ganglion, Meckel's Ganglion and Sluder's Ganglion after the physician who first described it's role in treating headaches in 1908.

While many medications can be utilized with SPG Blocks there is no study that has shown anything to be more effective than lidocaine.  Lidocaine is a natural anti-inflamatory with positive cardiac effects in the presence of irregular heart rhythm.  It is commonly utilized as dental anesthetic.

Drugs.com list 66 drugs to treat migraines, including triptans but none have been shown to be more effective than SPG Blocks though there is a massive amount of drug side effects associated with these medications.  All of these medications can be helpful and  SPG Blocks are safe to be used in combination with any headache or migraine medication.

Most importantly,  SPG Blocks can give the fastest relief possible with the lowest risk of medication side effects.  Patient may find that if they self-administer SPG Blocks they require far lower doses of medication if they need it at all.

There are side effects to Sphenopalatine Ganglion Blocks but in general they are positive.  About 1/3 of essential hypertension can be cured with SPG Blocks.  SPG Blocks can relieve anxiety, depression and stress.  The blocks can relieve a wide range of eye, ear, nose , sinus and jaw pains.  A 1930 article "Sphenopalatine Phenomena"  by Hiram Byrd in Annals of Internal Medicine (JAMA) showed almost 100% success in 10,000 blocks in 2000 patients with virtually no negative side effects.

This amazing technique almost became lost as part of forgotten medicine when Big Pharma and pharmaceuticals changed medicine starting in the 1940's.  This technique may have been lost forever but returned after the publication of a popular book "Miracles on Park Avenue" which detailed the practice of Dr Milton Reder an octogenerian  New York City Otolaryngologist whose entire practice focused on treating patients utilizing only Sphenopalatine Ganglion Blocks.

Injection of the Sphenopalatine Ganglion may be a way to increase effectiveness of the block in an acute severe headache.  Dentists are the experts at the intraoral injection through the greater palatine canal.  Extra-oral injections may be done via the Suprazygomatic Approach without fluoroscopy, usually by a Neuromuscular dentist trained in treating TMJ /TMD and orofacial pain or ENT's with extensive experience in treating chronic pain patients.

Sphenopalatine Ganglion Blocks are also very effective for treating TMJ disorders and associated Myofascial Pain and Dysfunction.  TMD and MPD are the primary underlying cause of all tension headaches and muscle contraction headaches.  

Neuromuscular Dentistry utilizes the Myomonitor that has a fifty year safety record as a neuromodulation unit for the trigeminal and facial nerves as well as the sympathetic and parasympatheetic fibers of the autonomic system that pass thru the SPG.

The use of a Diagnostic Neuromuscular Orthotic is often the first step in permanently eliminating Tension-Type Headaches.

Learn more at www.SphenopalatineGanglionBlocks.com

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posted by Dr Shapira at 8:53 AM

Saturday, December 22, 2018

Sphenopalatiine Ganglion (SPG) Blocks: Most Comprehensive information on the Miracle Blocks featured in "MIRACLES ON PARK AVENUE"

The Sphenopalatine Ganglion Block (SPG) was featured in the book "Miracles on Park Avenue" 

SPG Blocks are considered a first line treatment for Headaches, Migraines, Trigeminal Autonomic Cephalgias and all types of headaches.

There are numerous posts on this sitee oon thee topic but the most comprehensive information based on peer reviewed journals, pubmed and many other sources is at the website http://www.sphenopalatineganglionblocks.com.

It has the top rated blog site on SPG Blocks also known as Pterygopalatine Ganglion Blocks, Nasal Ganglion Block, Sluder's Ganglion Block and Meckel's Ganglion  Block.

There is a reddit page on these blocks as well featuring compelling patient videos:  https://www.reddit.com/r/SPGBlocks/

Patients wiith TMJ Disorders and Headaches or Migraines will also find comprehensive information at http://www.ThinkBetterLiife.com

Dr Shapira currently has a paper accepted by Cranio Journal: The Journal of CranioMandibular and Sleep Practice that diiscusses utiliizing Sphenopalatine Ganglion Blocks and Neuromuscular Dentistry to finally propeerly address chronic headache pain that addresses both the Trigeminal Nervous Systtem, the TMJoints and the Autonomic Nervous System, ie the Sympathetiic and Parasympathetic nerves of the Sphenopalatine Ganglion.

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posted by Dr Shapira at 8:16 AM

Monday, October 29, 2018

Chicago Pediatric Headache and Migraine: Self-Administered Sphenopalatine Gangliuon Blocks and Neuromuscular Dentistry are Key

An article in Neurology advisor (see link below)  discusses the use of SPG Blocks to treat pediatric headaches and migraines.  The study included 310 procedures on 200 children ranging from 7 to 18 years of age.  In 10 minutes after the block a significant number of children reported a 2 point drop in pain levels.
Th e use of SP)G blocks for treating pediatric headaches is a blessing for both children and parents.  The video below is of a 12 year old who presented with severe migraine and was able to find relief and learn how to Self-Administer and SPG Block.
The study looked at treatment of pain severe enough to require an ER or Physician visit.  The real beauty of SPG Blocks they can be used at the onset of pain to prevent a full attack and they can be used prophylactically to prevent migraines.
Pediatric headaches and migraines should be addressed as soon as possible to eliminate both physiologic and psychological effects on children.  Typically Sphenopalatine Ganglion Blocks are preformed by physicians.   Self-Administration is a complete game changer for quality of life of both children and their parents.  It is extremely safe and typically uses 2% lidocaine without epinephrine.  Lidocaine has natural anti-inflammatory properties.  An added benefit is the incredible savings involved.  A trip to the Emergency room can cost hundreds or even thousands of dollars and creates a major life disruption while self administering an SPG Blocks takes minutes to provide relief and is under $1.00 in cost.  It is far safer than any of the medications used to treat headache and migraine and it avoids a great deal of unnecessary and invasive diagnostic testing.  A recent article in Current Opinions in Pediatrics Sept 17, 2018 “Migraine in Children: presentation, disability and response to treatment” summarizes that “Recent research suggests that preventive medications may not be more effective than placebo.”   Medication is clearly not the best approach to most pediatric migraines.
This is a video of a pediatric patient who presented with a severe disabling headache and was treated with an SPG Block.
The Sphenopalatine  Ganglion (SPG) is the largest Parasympathetic Ganglion of the head and is part of the autonomic nervous system.
There are two primary divisions of our nervous system, the Somato-Sensory nervous system that we utilize to take in our environment and control our bodies.  We are well aware of utilizing the Somato-Sensory syustems.  The Autonomic nervous system is the second division and it controls the underlying physiologic systems that help us survive, control sleep, hunger, digestion, heart rate, and much much more.
The autonomic also has two divisions the Sympathetic and the Parasympathetic system:
The Sympathetic which controls our “Fight or Flight” reflex prepares our body for action and typically responds to stress from our environment.  An example would be meeting a large angry  grizzly bear, our bodies prepare to run like hell or get ready for the fight of our life.  Our body release Cortisol the stress hormone and adrenaline.  Our blood is shunted to the brain, heart and  other muscles.  Our senses become very acute.  The Sympathetic response is a reflex that provides for the survival of the individual.
The Parasympathetic system is just the opposite.  It is often called the “Eat and Digest” or the “Feed and Breed” reflex.  It is where we are laid back and relaxed.  It is where we are aware of love, warmth and comfort of others.  It is where we relax and recover, sleep, dream and much more.  It is called tthe “Survival of the Species” reflex rather than the individual.
The Sphenopalatine ganglion has cell bodies of the Parasympathetic nerves but it is the major supplier of both sympathetic and parasympathetic nerves to the head and especially to the Trigeminal Nervous System where almost 100% of headaches and migraines are initiated controlled.  The Sphenopalatine Block acts as a reset button turning off Sympathetic stress responses and turning on the Parasympatheetic system, similar to hitting Control/Alt/ Delete when your computer freezes up.  Anxiety reduction  that is obtained with SPG Blocks is a godsend for severely anxious pediatric migraine patients.
New studies have shown that SPG Blocks can eliminate about 1/3 of essential hypertension.  This would be especially useful in children with hypertension.
While utilizing Sphenopalatine Ganglion Blocks to treat, stop and prevent headaches and migraines an enormous benefit it is important to understand that many of these issues are initially caused by underdeveloped maxillas and small pediatric airways. This can lead to sleep disorders including Snoring, Sleep Apnea, Restless Legs, UARS, Nocturnal Enuresis (Bed Wetting), ADD, ADHD, Stress disorders, Anxiety and many other problems.
Early orthopedic/orthodontic treatment can change the development of the jaws and grow a lifetime of better physiology and healthier sleep and Breathing.
The VIVOS DNA Appliance and Epigenetic Orthodontics can be utilized to address older children and adults who have small airways and Orthopedically grow larger jaw s and Pneumopedically grow larger airways.
All children with Headaches, Earaches, Migraines, ADD, ADHD, and even simple snoring should have a sleep study to evaluate their airways.
Dr Shapira practices in Highland Park, Il , Visit his websites http://www.ThinkBetterLife.com to learn more.

Link for Referral to Dr Shapira:  https://thinkbetterlife.com/referrals/

Link to over 100 PATIENT TESTIMONIALS

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

Link to Neurology Advisor article:

https://www.neurologyadvisor.com/migraine-and-headache/sphenopalatine-ganglion-block-can-relieve-migraine-in-children/article/642373/

This link is to an article on Current Treatment for pediatric migraine, after a quick review you will understand superiority of SPG Blocks.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5394581/

PubMed Abstract:
Curr Opin Pediatr. 2018 Sep 17. doi: 10.1097/MOP.0000000000000694. [Epub ahead of print]

Migraine in children: presentation, disability and response to treatment.

Abstract

PURPOSE OF REVIEW:

The current review presents findings from investigations of migraine in children. The presentation of pediatric migraine, related consequences, and medication treatments are reviewed.

RECENT FINDINGS:

A number of advancements have been made in the study of the presentation, disability, and treatments for migraine in children. However, recent research suggests that not all approaches are equally effective in the treatment of migraine in children. Specifically, a recent study comparing pharmacological interventions found that preventive medications were not statistically more effective than placebo in children. Consistent findings showing clinically meaningful placebo response rates, shorter duration of headaches and other characteristic features (e.g. frontal, bilateral location) have been barriers to the design of randomized clinical trials in children and adolescents with migraine. Better understanding of treatment mechanisms for medication interventions is needed.

SUMMARY:

Several migraine treatments have determined to be effective for use in children but few controlled studies have evaluated the effectiveness of medication treatments. Recent research suggests that preventive medications may not be more effective than placebo. Additional research is needed to evaluate the effectiveness of medication treatment in migraine headache care.
PMID:
30234648
DOI:

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posted by Dr Shapira at 7:19 AM

Friday, September 14, 2018

Preventing Seizures with Sphenopalatine Ganglion Blocks

The Sphenopalatine Ganglion Block had many uses in the past many of which became forgotten medicine with the onset of new pharmaceuticals.  Seizures were once treated with SPG Blocks as described in "Sparer W. Cessation of convulsive seizures following injection of alcohol into spheno-palatine ganglia. Three Cases."

Sphenopalatine Ganglion Blocks are safe, easy to administer and still have a place in treatment of seizures resistant to medications and in patients where medication may be inappropriate.

Self-Administration allows patients to self administer the blocks at home for prevention of seizures.  This avoids the more invasive alcohol block.

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posted by Dr Shapira at 9:07 AM

Wednesday, April 18, 2018

HATE YOUR CPAP? Get INSPIRED! New Device Treats Sleep Apnea successfully


INSPIRE is a new therapy for Sleep Apnea.

CPAP  and Oral Appliances have been the first line treatments for mild to moderate sleep apnea and CPAP is the gold standard for severe sleep apnea.

While CPAP is extremely effective only 25% of patients actually utilize t as prescribed and 60% of patients refuse or fail CPAP completely.

Oral Appliances have been the choice of most patients who do not tolerate CPAP but these new studies show that there is a new effective treatment.  Studies have shown that over 90% of patients offered a choice of CPAP or an Oral Appliance chose the Oral Appliance therapy.  Chicago testimonials for Oral Appliance Therapy can be found at:  https://thinkbetterlife.com/category/blogs/

Now that there is a new player and patients have more choices, a very positive development.

Morbidly obese patients are probably still going to need CPAP but just as oral appliances are used with CPAP to lower pressure cotreatment with inspire will probably be possible as well.

Inspire or Hypoglossal nerve stimulation (HNS) therapy is the newest player on the block.

There are three new studies (abstracts below) on the use of Upper Airway Stimulation with the Inspire device.  This is GOD NEWS for patients who HATE CPAP!

North Shore Health System is the first in Chicago to offer Inspire Therapy.
https://www.northshore.org/sleep-center/procedures/inspire-therapy/

While there are risks associated with this therapy, they are low and the risks of untreated sleep apnea are much greater.


Conclusions in Upper Airway Stimulation for Obstructive Sleep Apnea:  5- Year Outcomes. showed Improvements in sleepiness, quality of life, and respiratory outcomes are observed with 5 years of UAS. Serious adverse events are uncommon. UAS is a nonanatomic surgical treatment with long-term benefit for individuals with moderate to severe OSA who have failed nasal continuous positive airway pressure.  The study showed the responder rate was 63% at 5 years and that there was a 6% rate of serious device-related events related to lead/device adjustments.

The study in  2018 Mar 2. pii: S0196-0709(18)30077-2. doi: 10.1016/j.amjoto.2018.03.003. "Uvulopalatopharyngoplasty vs CN XII stimulation for treatment of obstructive sleep apnea: A single institution experience.  tShowed that Inspire was more successful than traditional UP3 surgery with 65%  HNS patients achieving an AHI of under 5  ie HNS is  "curative" in the majority of patients. "For select patients, HNS therapy provides excellent objective improvement in outcome measures."





 2018 Mar 1:194599818762383. doi: 10.1177/0194599818762383. [Epub ahead of print]

Upper Airway Stimulation for Obstructive Sleep Apnea: 5-Year Outcomes.

Abstract

Objective To present 5-year outcomes from a prospective cohort of patients with obstructive sleep apnea (OSA) who were treated with upper airway stimulation (UAS) via a unilateral hypoglossal nerve implant. Study Design A multicenter prospective cohort study. Setting Industry-supported multicenter academic and clinical trial. Methods From a cohort of 126 patients, 97 completed protocol, and 71 consented to a voluntary polysomnogram. Those having continuous positive airway pressure failure with moderate to severe OSA, body mass index <32 kg="" m="" span="" style="font-size: 0.8461em; line-height: 1.6363em; position: relative; top: -0.5em; vertical-align: baseline;">2
, and no unfavorable collapse on drug-induced sleep endoscopy were enrolled in a phase 3 trial. Prospective outcomes included apnea-hypopnea index (AHI), oxygen desaturation index, and adverse events, as well as measures of sleepiness, quality of life, and snoring. Results Patients who did and did not complete the protocol differed in baseline AHI, oxygen desaturation index, and Functional Outcomes of Sleep Questionnaire scores but not in any other demographics or treatment response measures. Improvement in sleepiness (Epworth Sleepiness Scale) and quality of life was observed, with normalization of scores increasing from 33% to 78% and 15% to 67%, respectively. AHI response rate (AHI <20 and="" events="" hour="" per="">50% reduction) was 75% (n = 71). When a last observation carried forward analysis was applied, the responder rate was 63% at 5 years. Serious device-related events all related to lead/device adjustments were reported in 6% of patients. Conclusions Improvements in sleepiness, quality of life, and respiratory outcomes are observed with 5 years of UAS. Serious adverse events are uncommon. UAS is a nonanatomic surgical treatment with long-term benefit for individuals with moderate to severe OSA who have failed nasal continuous positive airway pressure.

KEYWORDS:

cranial nerve; device; device apnea hypopnea index; hypoglossal nerve; implant; long term; obstructive sleep apnea; polysomnogram; quality of life; sleep; sleepiness; surgery; upper airway stimulation
PMID:
 
29582703
 
DOI:
 
10.1177/0194599818762383

Upper Airway Stimulation for Obstructive Sleep Apnea: Results from the ADHERE Registry.

Boon M, et al. Otolaryngol Head Neck Surg. 2018.

Abstract

Objective Upper airway stimulation (UAS) is an alternative treatment option for patients unable to tolerate continuous positive airway pressure (CPAP) for the treatment of obstructive sleep apnea (OSA). Studies support the safety and efficacy of this therapy. The aim of this registry is to collect retrospective and prospective objective and subjective outcome measures across multiple institutions in the United States and Germany. To date, it represents the largest cohort of patients studied with this therapy. Study Design Retrospective and prospective registry study. Setting Ten tertiary care hospitals in the United States and Germany. Subjects and Methods Patients were included who had moderate to severe OSA, were intolerant to CPAP, and were undergoing UAS implantation. Baseline demographic and sleep study data were collected. Objective and subjective treatment outcomes, adverse events, and patient and physician satisfaction were reviewed. Results The registry enrolled 301 patients between October 2016 and September 2017. Mean ± SD AHI decreased from 35.6 ± 15.3 to 10.2 ± 12.9 events per hour ( P < .0001), and Epworth Sleepiness Scale scores decreased from 11.9 ± 5.5 to 7.5 ± 4.7 ( P < .0001) from baseline to the posttitration visit. Patients utilized therapy for 6.5 hours per night. There were low rates of procedure- and device-related complications. Clinical global impression scores demonstrated that the majority of physicians (94%) saw improvement in their patients' symptoms with therapy. The majority of patients (90%) were more satisfied with UAS than CPAP. Conclusions Across a multi-institutional registry, UAS therapy demonstrates significant improvement in subjective and objective OSA outcomes, good therapy adherence, and high patient satisfaction.

PMID

 29557280 [ - as supplied by publisher]


 2018 Mar 2. pii: S0196-0709(18)30077-2. doi: 10.1016/j.amjoto.2018.03.003. [Epub ahead of print]

Uvulopalatopharyngoplasty vs CN XII stimulation for treatment of obstructive sleep apnea: A single institution experience.




Abstract

OBJECTIVES:

Hypoglossal nerve stimulation (HNS) therapy is an emerging surgical treatment for select patients with obstructive sleep apnea (OSA). This study aims to compare outcomes in patients with moderate to severe OSA who underwent HNS surgery (Inspire Medical Systems) and those who underwent traditional airway reconstructive surgery, specifically uvulopalatopharyngoplasty (UPPP).

METHODS:

Patients who underwent HNS implantation (n = 20), all with moderate to severe OSA, inability to adhere to positive pressure therapy, and compliant with previously published inclusion criteria, were compared to a historical cohort that were intolerant of CPAP with similar inclusion criteria who all underwent UPPP (n = 20) with some also undergoing additional procedures such as septoplasty/turbinate reduction. Data including body mass index (BMI), pre- and post-implant apnea-hypopnea index (AHI) were assessed.

RESULTS:

For patients who underwent HNS, mean preoperative BMI was 28.0. Mean AHI decreased significantly from 38.9 ± 12.5 to 4.5 ± 4.8. All patients achieved an AHI < 20 post implant with 65% (13/20) with an AHI ≤ 5. For patients who underwent traditional airway surgery, mean preoperative BMI was 27.5; mean AHI decreased from 40.3 ± 12.4 to 28.8 ± 25.4.

CONCLUSION:

While both traditional surgery and HNS are effective treatments for patients with moderate to severe OSA with CPAP intolerance, our study demonstrates that HNS is "curative" in normalizing the AHI to <5 excellent="" for="" hns="" improvement="" in="" majority="" measures.="" objective="" of="" outcome="" p="" patients.="" patients="" provides="" select="" the="" therapy="">

KEYWORDS:

Apnea hypopnea index; Hypoglossal nerve stimulation; Obstructive sleep apnea; Upper airway surgery; Uvulopalatopharyngoplasty
PMID:
 
29540289
 
DOI:
 
10.1016/j.amjoto.2018.03.003

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posted by Dr Shapira at 1:33 PM

Thursday, March 29, 2018

Management of Cluster Headaches with Sphenopalatine Ganglion Blocks. What is the Best Mode of Administration of SPG Blocks for Cluster Headaches.

What is the best method of delivering a SPG Block?  There are many alternatives for delivering SPG Blocks, I personally feel that self-administration is the best approach for the majority of patients.  I utilize a wide variety of methods in some circumstances.
An excellent new article "Sphenopalatine Ganglion Block (SPG) in the Management of Chronic Headaches" in Current Pain and Headache Reports by Jeffery Mojica, Bi Mo & Andrew Ng does an excellent job in discussing both pathogenesis and treatment of Cluster Headaches utilizing Sphenopalatine Ganglion Blocks.
This article will discuss only that portion of their article dealing with Cluster Headaches but the article concluded in part that ", SPG blockade is a safe and effective treatment for chronic headaches such as cluster headaches, migraines, and other trigeminal autonomic cephalalgias"
Cluster Headache is one of the Trigeminal Autonomic Cephalgias. According to the article  "The autonomic symptoms of the various forms of headaches mimic the activation of the SPG. Therefore, the SPG has become a therapeutic target of interest. Symptoms such as lacrimation, conjunctival injection, nasal congestion, rhinorrhea, forehead sweating, and periorbital edema are common autonomic manifestations of trigeminal autonomic cephalalgias (TACs). The presence of these symptoms suggests that SPG may be a key structure in their pathogenesis."
TACs include cluster headache (CH), paroxysmal hemicranias (PH), short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT), Long-lasting autonomic symptoms with hemicrania (LASH), Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA)and hemicrania continua (HC).
"Cluster headache is the most common type of TACs. CH is characterized by unilateral headaches in Maxillary Division of the Trigeminal Nerve distribution that are classically associated with parasympathetic disruption, causing lacrimation, conjunctival injection, nasal congestion, and rhinorrhea."
The Sphenopalatine Ganglion has a very long history in the treatment of chronic headaches, migraines and Cluster headaches.  It was originally described by Greenfield Sluder in 1903 in case now thought to be a cluster headache.  The Sphenopalatine Ganglion (SPG) has many names including Sluder's Ganglion, the Nasal Ganglion, the Pteryggoalatine Ganglion named for its location in the Pteryggopalatine fossa, anr Meckel's Ganglion.
The Sphenopalatine Ganglion is the largest parasympathetic ganglion of the head and in addition to parasympathetic fibers it also carries somatosensory fibers and sympathetic fibers.  According to the article "The sphenopalatine ganglion is activated when the superior salivatory nucleus receives stimulation from the trigeminal afferent nerves. This results in parasympathetic activation of the meningeal vessels, lacrimal glands, nasal, and pharyngeal mucosa. This signaling pathway is referred to as trigeminal-autonomic reflex."  The Vascular and Neurogenic type headache pain is secondary to the release of vasoactive peptides.
This review cited five studies on SPG Blocks for Cluster Headache.  The first by Devoghel looked at 120 patients treated with Sphenopalatine Blocks by Supra-Zygomatic injection.  103 (94%) experienced complete relief and 17 reported no relief.
The second study looked at was by Barre of 11 Cluster headache patients treated with Intranasal cotton-tipped application of cocaine or lidocaine. All of the patients in this smaller study  reported a minimum of than reduction in headache intensity.  This study utilized the same technique originally described by Sluder in 1903.
The third study was by Kittrelle et al. was small with only 5 patients and utilized 4% lidocaine delivered by intranasal droplet.  4 of the 5 patients experienced a 75% decrease in headache intensity.
The fourth study by Robbins looked at 30 patients where 4% lidocaine was deliered by intranasal spray and 16 or slightly more than half experienced mild to moderate relief.  14 of the patients experienced no relief.
The last study by Costa et al.was a double-blind, placebo-controlled study  with rhinoscopic-guided bilateral intranasal cotton-tipped application of 10% cocaine or 10% lidocaine.   All patients reported complete relief with application of both lidocaine and cocaine.  This technique again utilized Sluder's original application technique.
There are three newer FDA approved catheter devices for delivering Sphenopalatine Ganglion blocks as well.
There is no question about the effectiveness of of Sphenopalatine Ganglion Block in the treatment of Cluster Headache.  What is amazing is that the Sphenopalatine Ganglion had become what is called "Forgotten Medicine"  Many excellent techniques get "lost" when newer techniques come along.  The era of polypharmacy approach to headaches has been over 50 years in the making.  Research and research money is spent looking for the "Magic Cure" or "magic pill" to treat  specific issues and doctors are never trained in old techniques.
The SPG Block is a perfect example of "Forgotten Medicine"  This is a video of a physician who had a severe disabling headache as a young boy and was treated with an SPG Block.  This boy decided to become a physician because of this experience, he wanted to help others as he had been helped.  Unfortunately, he was never taught or learned about SPG Blocks and after 10 years in practice he quit because he was unable to help patients in the manner he was helped.  He became an artist and makes magnificent trees.  This video was taken the day he learned what a SPG Block actually was.
https://www.youtube.com/watch?v=Sn46l_nH9-A&t=30s

The history of SPG Blocks began with Greenfield Sluder in 1903.  He published many articles on these blocks and wrote two books.   The first in 1918"Concerning Some Headaches and Eye Disorders of Nasal Origin" and the second "Nasal Neurology, Headaches and Eye Disorders" while he was a clinical professor and Director of the Department of Oto-Laryngology at Washington University School of medicine in St Louis.
There was a great deal of interest in these blocks and in 1930 Hiram Byrd MD and Wallace Byrd AB. wrote a paper published in the Annals of Internal Medicine (JAMA) on Phenopalatine Phenomena" that looked at 10,000 blocks in over 2000 patients.
This amazing block almost disappeared but in 1986 a book was published "Miracles on Park Avenue" by Albert Gerber about the medical practice of Milton Reder MD a world-famous New York City Otolarymgologist whose entire practice was utilizing SPG Blocks to treat a wide variety of chronic pain disorders with extreme success in thousands of patients including senators, generals, magnates, kings, Hollywood and Broadway stars and many prominent medical practitioners.  Dr Reder and this book written about this "Miracle Block" probably saved this treatment from the dustbin of obscurity.
I originally learned the technique in 1986 when a patient gave me a copy of the book and asked me to find someone in Chicago who used this technique.  I read this book in one sitting and found there was no one using it.  I finally found a colleague in the TMJ field in Kansas City who knew the technique, Dr Jack Haden and learned it from him.
I have been using this remarkable block since 1986.  Initially, I used a 10% cocaine solution but later switched to 4% and the 2% lidocaine.  I used the same technique as both Sluder, Byrd and Reder but later switched to a cotton-tipped catheter that allowed continuous capillary release of anesthetic.
Looking at these studies you will see that they use either lidocaine or cocaine and both are effective.  The applicator is more effective than drops which are more effective than the sprays of lidocaine.  Devoghel  used an injection technique utilizing alcohol which is longer lasting than  lidocaine or cocaine but carries more risk.  This was described by both Sluder and Byrd in their publications.
I believe the best approach is to teach patients to self-administer SPG Blocks with cotton tipped nasal catheters that continually provide anesthetic to the mucosa over the ganglion.    Some nasal passages are difficult to negotiate.  There are three new devices made to deliver SPG Blocks, they are the Sphenocath, the Allevio and the TX 360.  They are all nasal catheters used like "squirt guns"  They care all more effective than lidocaine spray or drops.  They are relatively expensive devices, $75.00 for a single use.  Physicians typically charge $750.00 per bilateral block.
I teach patients to Self-Administer SPG Blocks with cotton-tipped applicators but for some difficult access noses I teach patients to self-administer with a Sphenocath device which can be reused by a patient.  Patients can also self-administer with the TX 360 but it is strictly a single use device.
The use of Afrin (oxymetazoline ) spray can shrink mucosal membranes making self administration easier and I supply patients with spray bottles for lidocaine so they can numb nasal mucosa prior to self administration of SPG Block.
The advantage to self-administration is it is available to the patient on an as needed basis.  This allows the patients to avoid repeated trips to the ER or physician offices.
SPG Blocks can also be utilized to treat other pain disorders like Fibromyalgia. This video is a disabled Israeli veteran who suffered for nine years from Fibromyalgia before trying SPG Block.
https://www.youtube.com/watch?v=A5xUFtuZe_Y

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posted by Dr Shapira at 1:26 PM

Thursday, March 22, 2018

Anxiety And Migraine: Management with Sphenopaltine Ganglion Can Prevent or Eliminate Migraines

Migraine, Anxiety and Depression can all be sucessfully and treated with "Self Administered Sphenopalatine Ganglion Blocks"

Migraine and Anxiety are linked by the involvement of the Trigeminal Nerve and particularly the sympathetic autonomic nerves that pass thru the SphenoPalatine Ganglion (SPG).  The American Migraine Foundation believes that the majority of Migrainers (50-60%) also have anxiety disorders.  Migraine patients who do not have anxiety disorders frequently will experience anxiety during a migraine attack or even with prodromal symptoms.

Anxiety and Depression are also related and about 25-30% of Migraine patients have both Anxiety and Depression making treatment and management of migraine far more difficult.  Special care should be exercised in these patients who are at high risk for progressing to Chronic Migraine as well as Intractable / Refractory Chronic daily headache or New Persistent Daily Headache.

These patients often present with symptoms of Sympathetic Overload or Autonomic Dysregulation which can cause:
  • Shortness of breath
  • Increased heart rate
  • Chest tightness
  • Sensation of throat closing
  • Vertigo
  • Dizziness
  • Nausea
  • Double vision
  • Sweating
  • Difficulty thinking
  • Cold hands and feet

Hypervigilance and  Catastrophizing often leaves patients consumed with fear and feelings of hopelessness.  Depression can become severe and suicidal ideations may occur but are often denied by patients.  The stimulation or blocking of this ganglion

The SOAP approach to diagnosis can help overcome these issues but due to insurance issues and financial obstacles most doctors are typically rushed for time.
S. or Subjective considerations are often the most important part of an evaluation      and require a significant amount of face to face physician patient time.
O. or Objective findings are usually secondary.  CAT Scans, MRIs, Blood Panels       and other objective tests based on Subjective Evaluation are ordered.
A.  Assessment is the actual process of integrating both the subjective &             objective data.  Unfortunately, both objective tests ordered and assessment  
are compromised due to insufficient time spent gathering Subjective data.
P.  Plan is the method to address these issues.  

Medication Management has become the "Norm" for treating these problems but an older procedure called a SphenoPalatine Ganglion Block (Pterygopalatine Ganglion, Nasal Ganglion or SPG) may be the best first line treatment.  Prior to the explosion of pharmaceuticals available this procedure was routinely used to treat and eliminate a wide variety of conditions including Headache, Migraine, Cluster Headache, Sluder's Neuralgia, Trigeminal Neuralgia and a variety of ear pains, eye pains and sinus pains.

The Sphenopalatine Blocks have also been shown to treat anxiety and depression as well as PTSD.  Another Autonomic block the Stellate Ganglion Block has shown promise as a "One Shot Cure for PTSD"

The SPG Block was the subject of a 1986 book called "Miracles on Park Avenue" about Milton Reder who utilized only SPG blocks and treated patients from around the world.  In 1930 Hiram Byrd MD wrote an article called Sphenopalatine Phenomena detailing the amazing results of over 10,000 SPG Blocks in over 2000 patients.  Dr Greenfield Sluder first described the Sphenopalatine Ganglion Block in 1903 and in 1918 wrote the book "Concerning Some Headaches and Eye Disorders of Nasal Origin" and in 1927 the  book "Nasal Neurology:  Headaches and Eye Disorders"

These blocks have resurfaced in 21st century medicine after the introduction of three new FDA  devices to deliver the blocks, the Sphenocath, the Allevip and the TX 360.  They are utilized for treating Intractable and refractory headaches and Migraines, https://www.sphenopalatineganglionblocks.com/intractable-headaches-migraines-sphenopalatine-ganglion-spg-blocks-may-fastest-safest-treatment/.

Self Administration of Sphenopalatine Ganglion Blocks have enormous potential for decreasing and eliminating pain and anxiety and many other problems.  The effect on quality of life is exceptional because patients are now in control of their pain without dangerous or addictive medication.  The vale of eliminating trips to the ER and time spent in hospital and physicians offices waiting for treatment is incalcuable.

A recent editorial declared the Sphenopalatine Ganglion Block a medical miracle that is vastly underutilized. 
https://www.sphenopalatineganglionblocks.com/sphenopalatine-ganglion-block-underutilized-tool-pain-management/

Another recent article showed that SPG Blocks could eliminate about a third of Essential Hypertension cases.  https://www.sphenopalatineganglionblocks.com/new-studies-point-common-etiologic-cause-migraines-essential-hypertension-spg-blocks-missing-piece/

An article in December 2017 did a complete review of the science and treatments associated with the Sphenopalatine Ganglion..
https://www.sphenopalatineganglionblocks.com/sphenopalatine-ganglion-block-radiofrequency-ablation-neurostimulation-systematic-review/

Neuromuscular Dentistry has always been extremely predictable in treating chronic head and neck pain associated with TMJ and occlusal causes.  Much of the success in Neuromuscular Dentistry in eliminating headaches and migraines is probably due to the fact that the Myomonitor, which relaxes muscles innervated by the facial and trigeminal nerves also acts as a Neuromodulation device on the Sphenopalatine Ganglion.  

The Myomonitor has an incredible history of safe use for over 50 years to relax muscles and modulate the Sphenopalatine Ganglion.  It is not sold or marketed for Neuromodulation of the Sphenopalatine Ganglion.

I routinely treat a wide variety of issues relating to TMJ disorders, MPD and Orofacial and Craniofacial Pain with Neuromusclar Dentistry, beginning with a diagnostic orthotic. I teach these  patients to Self Administer Sphenopalatine Ganglion Blocks with cotton tipped nasal catheters in my Highland Park, Il office..Visit www.ThinkBetterLife.com to learn more.

This link is to 32 patient testimonials of patients who utilize SPG Blocks. 
 https://www.youtube.com/playlist?list=PL5ERlVdJLdtllxAN1QwD7JU7Qo_ISoqvt


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posted by Dr Shapira at 8:50 AM

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