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.

Reference:
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]

Migraine Headaches Associated with Allergies & Response to Allergy Shots

A recent study published this month in the journal Headache reported an association of migraine headaches with allergy severity and response to allergy shots... but only in those less than 45 years of age.

The study suggested that lower "degrees of atopy" (or allergy) were associated with less frequent and disabling migraine headaches in younger subjects while higher degrees were associated with more frequent migraines. The administration of allergy shots was associated with a decreased prevalence, frequency, and disability of migraine headache in younger subjects.

The age cut-off used to described "younger" subjects depending on the measure described was either 40 years or 45 years.

Read the abstract here.

Of course, one must consider the possibility that perhaps what these patients are suffering from is not migraine headaches, but allergy triggered sinus headaches.

Our office provides allergy testing, allergy shots, and allergy drops. We also offer botox injections in the treatment of migraine headaches.

Reference:
Allergy and immunotherapy: are they related to migraine headache? Headache. 2011 Jan;51(1):8-20. doi: 10.1111/j.1526-4610.2010.01792.x. Epub 2010 Nov 4.

Botox Approved for Migraine Headaches in the United States

On October 15, 2010, the FDA approved botox for use in migraine headaches. It is hoped that eventually, this procedure will soon be covered by most health insurance companies rather than the few who do so now.

Dr. Chang has been performing botox injections for migraine headaches since 2005 along with for wrinkles, spasmodic dysphonia, cervical dystonias, oral-mandibular dystonias, etc.

Read the NYT article on the FDA approval here.

Read the FDA announcement here.