Sphenopalatine ganglion neuromodulation in migraine: What is the rationale?

Abstract

Objective: The objective of this article is to review the prospect of treating migraine with sphenopalatine ganglion (SPG) neurostimulation. Background: Fuelled by preliminary studies showing a beneficial effect in cluster headache patients, the potential of treating migraine with neurostimulation has gained increasing interest within recent years, as current treatment strategies often fail to provide adequate relief from this debilitating headache.Common migraine symptoms include lacrimation, nasal congestion, and conjunctival injection, all parasympathetic manifestations. In addition, studies have suggested that parasympathetic activity may also contribute to the pain of migraineurs.The SPG is the largest extracranial parasympathetic ganglion of the head, innervating the meninges, lacrimal gland, nasal mucosa, and conjunctiva, all structures involved in migraine with cephalic autonomic symptoms. Conclusion: We propose two possible mechanisms of action: 1) interrupting the post-ganglionic parasympathetic outflow to inhibit the pain and cephalic autonomic symptoms, and 2) modulating the sensory processing in the trigeminal nucleus caudalis. To further explore SPG stimulation in migraineurs as regards therapeutic potential and mode of action, randomized clinical trials are warranted.

Multimodal Frequency Treatment for Facial Pain Caused by Chronic Rhinosinusitis: A Pilot Study

“…In a study by Ansari et al [53], 95% of patients with facial pain at the beginning of the study reported significant improvement after the study. The facial pain effect size observed in our study (d = 0.96) was much higher than that estimated from Young et al's data (d = 0.51), likely due to the application of multimodal frequencies (70)(71)(72)(73)(74)(75)(76)(77)(78)(79)(80) Hz and 1 MHz) in the AxioSonic system. Our effect size for quality of life measures using the SNOT-22 questionnaire (d = 0.45) was lower than Young et al's paper [40] (d = 0.9).…”

“…The SPG is involved in tissue inflammation, lacrimation, mucus production and other parasympathetic processes [71][72][73][74]. Low frequency neurostimulation (20 Hz, much lower than ultrasound frequencies) of the SPG or the Vidian nerve leads to vasodilation and associated inflammation [75,76].…”

Relationship between serum levels of VIP, but not of CGRP, and cranial autonomic parasympathetic symptoms: A study in chronic migraine patients

“…In theory, together with CGRP, peripheral VIP levels could contribute to objectively monitor migraine status and response to preventive treatments (27,28), which could be of specific help for a more objective follow-up of patients included in clinical trials, especially in those involving the cranial parasympathetic system, such as the stimulation of the sphenopalatine ganglion (29). As an example of this, both CGRP and VIP blood levels have been shown to be significantly higher in CM patients responding to onabotulinumtoxinA as compared to nonresponders (27).…”

Evidence for Surgical Management of Facial Pain and Headache

“…42,44 Recent improvement in surgical technique and employment of of this therapy involves interruption of the postganglionic parasympathetic outflow and regulating the sensory inputs and processing in the nucleus caudalis of trigeminal. 39 Following the beneficial effect of this therapy in patients with cluster headache, this modality has gained interest in treating patients with migrainous headache. 39 However, the literature on SPG neuromodulation is mostly from small series of patients and needs to be validated by randomized clinical trials.…”

“…39 Following the beneficial effect of this therapy in patients with cluster headache, this modality has gained interest in treating patients with migrainous headache. 39 However, the literature on SPG neuromodulation is mostly from small series of patients and needs to be validated by randomized clinical trials.…”