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Pterygopalatine Fossa Blockade as Novel, Narcotic-Sparing Treatment for Headache in Patients with Spontaneous Subarachnoid Hemorrhage

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Abstract

Background

Severe headache is a hallmark clinical feature of spontaneous subarachnoid hemorrhage (SAH), affecting nearly 90% of patients during index hospitalization, regardless of the SAH severity or presence of a culprit aneurysm. Up to 1 in 4 survivors of SAH experience chronic headaches, which may be severe and last for years. Data guiding the optimal management of post-SAH headache are lacking. Opioids, often in escalating doses, remain the guideline-recommended mainstay of acute therapy, but pain relief remains suboptimal.

Methods

This study is a case series of adult patients who received bilateral pterygopalatine fossa (PPF) blockade for the management of refractory headaches after spontaneous SAH (aneurysmal and non-aneurysmal) at a single tertiary care center. We examined pain scores and analgesic requirements before and after block placement.

Results

Seven patients (median age 54 years, 3 men, four aneurysmal and three non-aneurysmal) received a PPF-block between post-bleed day 6–11 during index hospitalization in the neurointensive care unit. The worst pain recorded in the 24-h period before the block was significantly higher than in the period 4 h after the block (9.1 vs. 3.1; p = 0.0156), and in the period 8 h after the block (9.1 vs. 2.8; p = 0.0313). The only complication was minor oozing from the needle insertion sites, which subsided completely with gauze pressure within 1 min.

Conclusions

PPF blockade might constitute a promising opioid-sparing therapeutic strategy for the management of post-SAH headache that merits further prospective controlled randomized studies.

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Acknowledgments

Dr. Carolina B. Maciel has received the Claude D. Pepper Older Americans Independence Center Junior Scholar award that supports preclinical studies of mechanisms of secondary brain injury in a rodent cardiac arrest model. Gerard Garvan produced the graphs using R software.

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Authors and Affiliations

  1. Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA

    Cameron R. Smith, Cynthia Garvan, Erica Lobmeyer & Alberto Bursian

  2. Department of Neurology, McKnight Brain Institute, University of Florida College of Medicine, 1149 Newell Drive, L3-100, Gainesville, FL, 32610, USA

    W. Christopher Fox, Christopher P. Robinson, Marc-Alain Babi, Michael A. Pizzi, Carolina B. Maciel & Katharina M. Busl

  3. Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA

    Christopher P. Robinson, Marc-Alain Babi, Michael A. Pizzi, Carolina B. Maciel & Katharina M. Busl

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  1. Cameron R. Smith
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Contributions

Cameron R. Smith and Katharina M. Busl: Conception and design of the study, data interpretation, drafting of the article, critical revision of the article, final approval of the version to be published. Cynthia Garvan: Data analysis and interpretation, critical revision of the article. W. Christopher Fox and Carolina Maciel: conception of the study, data interpretation, critical revision of the article. Marc-Alain Babi, Michael A. Pizzi, Christopher P. Robinson: data interpretation, critical revision of the article. Erica Lobmeyer, Alberto Bursian: data collection, data interpretation, critical revision of the article.

Corresponding author

Correspondence to Katharina M. Busl.

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This study adheres to ethical guidelines and has approval from the local Institutional Review Board (IRB 201901207) including waiver of consent.

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Smith, C.R., Fox, W.C., Robinson, C.P. et al. Pterygopalatine Fossa Blockade as Novel, Narcotic-Sparing Treatment for Headache in Patients with Spontaneous Subarachnoid Hemorrhage. Neurocrit Care 35, 241–248 (2021). https://doi.org/10.1007/s12028-020-01157-1

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  • DOI: https://doi.org/10.1007/s12028-020-01157-1

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