Dr Heidi Moawad interviews Dr Alison Alford, a neurologist who specializes in pediatric headache medicine. She currently runs her own practice, Pediatric Headache Center of Richmond, in Richmond, VA.
Heidi Moawad, MD (HM): What are the challenges you face when it comes to pediatric migraine?
Alison Alford, MD (AA): One of the most difficult tasks, as you would imagine, is taking a history. I have some very little ones who have a difficult time describing the quality of their headaches. Describing symptoms is difficult enough for an adult. Treatments can be a very big hurdle. There is very little research in children and very few medication options that are approved for under aged 18 years. There is a lot involved in getting what our patients need.
HM: What are the criteria you use when deciding if a child is a good candidate for this treatment?
AA: I typically offer it to patients who have a high burden of frequency. I really prefer not to prescribe daily medications if I can avoid it. SPG blocks are minimally invasive and can sometimes provide up to months of relief with one block; they can also build on themselves and provide months of relief with a few weeks of therapy. If we can treat with just a rescue, then we don't necessarily need a SPG. Sometimes, however, we use it to break an intractable migraine as well, which can avoid IV therapy sometimes too.
HM: How did the children respond to the treatment?
AA: Most children respond very well and rapidly to the treatment. Sometimes within minutes. It can provide relief anywhere from 3 hours to 3 months. One of my patients got 9 months of relief and one, a year. Typically, I see anywhere from 2 to 6 weeks of relief with one block with peak around a month. Additionally, in two cases, treatment helped joint pain related Ehlers-Dahlos Syndrome and Complex Regional Pain Syndrome.
HM: How often do children typically need to repeat treatment and what are the signs that treatment effects were wearing off?
AA: I typically tell patients to call when they feel the next headache coming on and we can decide if we are at a time to do another. The two cases where it helped more generalized pain required 2 to 3 times a week (which ended up being unsustainable). They both had their symptoms return once the blocks stopped.
HM: How many pediatric migraines have you treated with SPG blocks?
AA: We have done at least a thousand procedures at this time. See the video of Dr Alford demonstrating the SPG block procedure, courtesy of WLKR CoastLive, here. [need to access link for here to work]
Mehta D, Leary MC, Yacoub HA, El-Hunjul M, Kincaid H, Koss V, Wachter K, Malizia D, Glassman B, Castaldo JE. The Effect of Regional Anesthetic Sphenopalatine Ganglion Block on Self-Reported Pain in Patients With Status Migrainosus. Headache. 2019 Jan;59(1):69-76.
Status migrainosus (SM) is defined as a debilitating migraine attack lasting more than 72 hours in patients previously known to suffer from migraine headache. Typically, these attacks fail to respond to over the counter and abortive medications. The sphenopalatine ganglion (SPG) plays a critical role in propagating both pain and the autonomic symptoms commonly associated with migraines. SPG block via transnasal lidocaine is moderately effective in reducing migraine symptoms, but this approach is often poorly tolerated and the results are inconsistent. We proposed that an SPG block using a suprazygomatic injection approach would be a safe and effective option to abort or alleviate pain and autonomic symptoms of SM.
Through a retrospective records review, we identified patients with a well-established diagnosis of migraine, based on the International Headache Society criteria. Patients selected for study inclusion were diagnosed with SM, had failed to respond to 2 or more abortive medications, and had received a suprazygomatic SPG block. Patients had also been asked to rate their pain on a 1-10 Likert scale, both before and 30 minutes after the injection.
Eighty-eight consecutive patients (20 men and 68 women) received a total of 252 suprazygomatic SPG block procedures in the outpatient headache clinic after traditional medications failed to abort their SM. At 30 minutes following the injections, there was a 67.2% (±26.6%) reduction in pain severity with a median reduction of 5 points (IQR= -6 to -3) on the Likert scale (ranging from 1 to 10). Overall, patients experienced a statistically significant reduction in pain severity (P < .0001).
The SPG is known to play an integral role in the pathophysiology of facial pain and the trigeminal autonomic cephalalgias, although its exact role in the generation and maintenance of migraine headache remains unclear. Regional anesthetic suprazygomatic SPG block is potentially effective for immediate relief of SM. We believe the procedure is simple to perform and has minimal risk.