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

Smith, Cameron R.; Fox, W. Christopher; Robinson, Carol; Garvan, Cynthia; Babi, Marc-Alain; Pizzi, Michael; Lobmeyer, Erica; Bursian, Alberto; Maciel, Carolina B.; Busl, Katharina M.

doi:10.1007/s12028-020-01157-1

Cited by 18 publications

(15 citation statements)

References 31 publications

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“…Another interventional treatment for SAH headache is a pterygopalatine fossa (PPF) blockade. Smith et al 12 performed a case series on seven adult patients who received a PPF block for the management of headache after spontaneous SAH. Patients were given a one‐time, bilateral suprazygomatic PPF‐block with ropivacaine and dexamethasone between 6 and 11 days post‐bleed, and headache pain was greatly alleviated in the study period of up to 8 h post block.…”

Section: Methodsmentioning

confidence: 99%

“…1 Severe, recurrent headaches are common in post-SAH patients, being classed as persistent headache attributed to past non-traumatic SAH if lasting for >3 months (per the International Classification of Headache Disorders, third edition, hereby referred to as post-SAH headache), 5 and their persistence for years is an important cause of post-SAH morbidity. [6][7][8] These headaches are a major clinical challenge in care, as they are the main cause of post-SAH pain; however, little data exists on the efficacy of analgesic medications and differential approaches in controlling these headaches 4,6,[9][10][11][12][13] which were briefly reviewed previously. 3 Persistent headaches are also common following ischemic stroke; 14 however, the differences in etiologic mechanism and patient population warrant focused study of these headaches in post-SAH patients.…”

Section: Introductionmentioning

confidence: 99%

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Headache persisting after aneurysmal subarachnoid hemorrhage: A narrative review of pathophysiology and therapeutic strategies

et al. 2022

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Objective This narrative review of the literature concerns persistent headache attributed to past non‐traumatic subarachnoid hemorrhage (SAH), based off demographic and clinical features, what are pathophysiologic mechanisms by which these headaches occur, which medical and interventional treatments have the most evidence for pain alleviation, and what pre‐clinical evidence is there for emerging treatments for these patients. Background Following initial stabilization and treatment of spontaneous SAH, most commonly due to aneurysmal rupture, headache in the immediate inpatient setting and persisting after discharge are an important cause of morbidity. These headaches often receive heterogenous treatment of uncertain efficacy, and the risk factors and pathophysiology of their development has received little study. Methods A narrative review of current literature discussing post‐SAH headache was conducted using a literature search in PubMed with search term combinations including “post subarachnoid hemorrhage pain”, “subarachnoid hemorrhage headache”, and “post subarachnoid hemorrhage headache”. Clinical studies mentioning headache after SAH and/or treatment in the abstract/title were included through March, 2022. Results and Conclusion Post‐SAH headaches are shown to decrease quality of life, have a multi‐modal pathophysiology in their occurrence, and only a select few medications (reviewed herein) have been demonstrated to have efficacy in alleviation of these headaches, while also harboring possible risks including vasospasm and re‐bleeding. An effective treatment paradigm of these headaches will include trials of evidence‐based therapeutics, rapid reduction of opioid medications if not effective, and consideration of multi‐modal pain control strategies including nerve blocks.

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Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Headache persisting after aneurysmal subarachnoid hemorrhage: A narrative review of pathophysiology and therapeutic strategies

et al. 2022

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“…were utilized at least occasionally by nearly one of ve respondents. While most published data on any of these treatments are based on case reports or smaller case series, experience with pterygopalatine fossa blocks, occipital nerve blocks and acupuncture have been reported with potentially promising results [15,16,40,41] and may offer potential additions to the multi-drug regimens that are most commonly employed. Providers considering such alternative strategies were more likely based in North Americalikely a re ection of the regional shift from opioid-based analgesia-and were more likely to be considered in a setting where the intensive care team was responsible for analgesia.…”

Section: Alternative Analgesic Strategiesmentioning

confidence: 99%

“…More recently, multimodal pharmacotherapy with agents such as gabapentinoids, magnesium infusions, corticosteroids, and utilization of nerve blocks have been reported [13][14][15][16].…”

Section: Introductionmentioning

confidence: 99%

Acute Headache Management for Patients with Subarachnoid Hemorrhage: An International Survey of Health Care Providers

et al. 2022

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Background: Severe headaches are common after subarachnoid hemorrhage (SAH). Guidelines recommend treatment with acetaminophen and opioids, but patient data show that headaches often persist despite multimodal treatment approaches. Considering an overall slim body of data for a common complaint affecting SAH patients during their intensive care stay, we set out to assess practice patterns in headache management among clinicians who treat patients with SAH.Methods: We conducted an international cross-sectional study through a 37-question web-based survey distributed to members of 5 professional societies relevant to intensive and neurocritical care from 11/2021-1/2022. Responses were characterized through descriptive analyses; Fisher's exact test was used to test associations.Results: Of 516 responses, 329/497 (66%) were from North America and 121/497 (24%) from Europe. 379/435 (87%) reported headache as major management concern for SAH patients. Intensive-care-teams were primarily responsible for analgesia during hospitalization (249/435, 57%), while responsibility shifted to neurosurgery at discharge (233/501, 47%). Most used medications were acetaminophen (90%), opioids (66%), corticosteroids (28%) and antiseizure medications (28%). Opioids or medication combinations including opioids were most frequently perceived as most effective, by 169/433 (39%, predominantly intensivists), followed by corticosteroids or combinations with corticosteroids (96/433, 22%, predominantly neurologists). Of medications prescribed at discharge, acetaminophen was most common (303/381, 80%), followed by opioids (175/381 [46%]), and antiseizure medications (173/381, 45%). Opioids during hospitalization were signi cantly more prescribed by intensivists, by providers managing higher numbers of SAH patients, and in Europe. At discharge, opioids were more frequently prescribed in North America. 299/435 (69%) indicated no change in prescription practice of opioids with the opioid crisis. Additional differences in prescription patterns between continents and providers, and inpatient versus discharge were found.Conclusions: Post-SAH headache in the intensive care setting is a major clinical concern. Analgesia heavily relies on opioids both in utilization and in perception of e cacy, with no reported change in prescription patterns for opioids for most providers despite the signi cant drawbacks of opioids.Responsibility for analgesia shifts between hospitalization and discharge. International and providerrelated differences are evident. Novel treatment strategies and alignment of prescription between providers are urgently needed.

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“…DCI has been associated with younger age and high score on the modi ed Fisher scale, however clear risk factors for DCI remain sparse [3,4]. Although promising medical and interventional therapies are undergoing trials to prevent DCI [3], few studies have evaluated associations between DCI and commonly used analgesic and anti-seizure medication dosages already utilized in the management of many SAH patients [6][7][8][9][10][11][12].…”

Section: Introductionmentioning

confidence: 99%

Evaluating common medications utilized in aneurysmal subarachnoid hemorrhage and association with delayed cerebral ischemia

Sorrentino

Eisinger

Maciel

et al. 2022

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Background Spontaneous aneurysmal subarachnoid hemorrhage (aSAH) recovery may be hampered by delayed cerebral ischemia (DCI). Herein, we sought to identify an association of DCI with frequently administered medications in the neurointensive care unit (neuro-ICU). Methods In this retrospective study, patients admitted to a tertiary care center neuro-ICU between 2012–2019 with aSAH who could verbalize pain intensity scores were included. Medication dosages and clinical characteristics were abstracted from the medical record. Both paired (within subjects) and unpaired (across subjects) non-parametric analyses were utilized to measure individual DCI risk for a given patient in relation to drug dosages. Results 119 patients were included; average age was 61.7 ± 15.2 (SD) years, 89 (74.7%) were female, and 32 (26.9%) experienced DCI during admission. Patients with DCI had longer length of stay (19.3 ± 7.4 vs 12.7 ± 5.3 days, p < 0.0001). The combination medication of acetaminophen 325 mg/butalbital 50 mg/caffeine 40 mg (A/B/C; Fioricet®) was associated with decreased DCI on paired (2.3 ± 2.0 vs 3.1 ± 1.9 tabs, p = 0.034) and unpaired analysis (1.84 ± 2.4 vs 2.6 ± 2.4 tabs, p < 0.001). No associations were found between DCI and opioids, dexamethasone, levetiracetam, or acetaminophen. Max and mean daily headache pain was not associated with DCI occurrence. Conclusion We identified a dose-response relationship between a commonly administered analgesic and DCI. A/B/C is associated with decreased DCI in this study both within and across subjects, while other medications are not associated with DCI.

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

Cited by 18 publications

References 31 publications

Headache persisting after aneurysmal subarachnoid hemorrhage: A narrative review of pathophysiology and therapeutic strategies

Headache persisting after aneurysmal subarachnoid hemorrhage: A narrative review of pathophysiology and therapeutic strategies

Acute Headache Management for Patients with Subarachnoid Hemorrhage: An International Survey of Health Care Providers

Evaluating common medications utilized in aneurysmal subarachnoid hemorrhage and association with delayed cerebral ischemia

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