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]