August 14, 2012

Intra-Nasal Trigger Point Injections for Facial Headache

Do you suffer from a stabbing headache in the areas denoted in red? Do these headaches seemingly come out of nowhere one day? Perhaps started after a viral upper respiratory infection?

You may be suffering from a condition known as contact point headache or a type of neuralgia involving one of the nerve plexuses found inside the nose:

• Anterior ethmoid neuralgia (Sluder's neuralgia)
• Sphenopalatine ganglion neuralgia (Pterygopalatine ganglion neuralgia)

This type of headache has often been confused with cluster headache, migraine without aura, sinusitis, or other undefinable pathology especially since CT scans and MRI scans that are obtained often do not reveal any tumor or presence of infection.

In the event of a contact point headache, surgical removal of the offending anatomic abnormality is curative.

However, for neuralgia, trigger point injections may be helpful according to a recent study. Using a 1:1 mixture of 0.5% bupivacaine and Kenalog-40, either the sphenopalatine ganglion or the anterior ethmoid neurovascular bundle or even both are injected. For the sphenopalatine ganglion, the injection is where the middle turbinate inserts into the lateral nasal wall. For anterior ethmoid injection, identify the arch where the middle turbinate inserts superiorly to the lateral nasal wall and inject 5mm above this site.

In a total of 882 nerve blocks in 147 patients, 99.3% had no complications. 2 patients reported visual changes that resolved within 2 days. More importantly, 81.3% claimed improvement in their headache, 17.9% reported no change and 0.79% reported worse pain after the injection.

The typical duration of pain relief was 3-4 weeks. As such, for continued pain relief, the injection needs to be repeated monthly on average.

Endoscopic neural blockade for rhinogenic headache and facial pain: 2011 update. Int Forum Allergy Rhinol. 2012 Apr 5. doi: 10.1002/alr.21035. [Epub ahead of print]

Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids.


Anonymous said...

I have been suffering from these exact symptoms for 9 months. It has been agonizing. 2 ENTS, who see nothing wrong, say its just anxiety and tension, been on anti anxiety meds with no avail for 7 months. The facial pain is like a bulls eye in the bridge of my nose and usually starts at the same time every day, it gradually gets worse in the course of the evening, to the center of my forehead, my temples and cheeks. I have now seen a neurologist who put me on migraine meds, nothing has changed. I still feel the pain every single day. This came out of nowhere one day after a sinus infection last spring. My life has not been too great, relationships, work, etc all have suffered since it happened. No doctor will believe me, they just keep tossing drugs at me. Nothing helps, painkillers, muscle relaxers, you name it, I've taken it. This sucks! I need help Dr. Chang. Are there any specialists you can recommend in North Eastern OH, Western PA who understand this condition?

Anonymous said...

While, in theory, any competent ENT can make the anterior ethmoid nerve syndrome diagnosis...patients often see multiple caregivers who seemingly are unable to do so. The challenge is in finding a physician who considers the diagnosis. Most never have heard of it.

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