Sphenopalatine ganglion block for postdural puncture headache: A review of current evidence

Table 1 Sphenopalatine ganglion blockade techniques

Technique	Ref.	Approach	Description	Key advantages	Key limitations/considerations
Trans nasal	Schaffer et al[13], 2015	Topical	A cotton-tipped applicator, catheter, or atomizer is used to apply a local anesthetic (e.g., lidocaine) to the nasal mucosa; an anesthetic is applied to the posterior pharyngeal wall mucosa; the goal is to diffuse the medication to the underlying sphenopalatine ganglion (SPG)	It is noninvasive and simple; quick to perform at the bedside; there is a low risk of serious complications; easily repeatable	Drug diffusion is inconsistent; shorter duration of the effect; the anesthetic dose is not precisely controlled; uncomfortable for patients
Transoral	Piagkou et al[11], 2012	Invasive	The needle is advanced through the hard palatine’s greater palatine foramen; the needle enters the pterygopalatine fossa; local anesthetic is injected directly into SPG; it is often performed under fluoroscopic guidance	This allows for the precise injection of a known volume; provides a more consistent and prolonged effect	Invasive: Risk of vascular injury and hematoma; risk of infection
Suprazygomati	Alseoudy et al[9], 2024	Invasive and ultrasound-guided	The needle is advanced superior to the zygomatic arch; the needle is guided to the pterygopalatine fossa to deliver anesthesia; the procedure is performed under real-time ultrasonographic guidance	Real-time visualization can improve the accuracy and safety of the procedure; it avoids radiation exposure	This requires significant ultrasound expertise and equipment; this is technically more challenging; risk of orbital injury
Infrazygomatic	Anthony Cometa et al[14], 2021	Invasive and fluoroscopy-guided	The needle is advanced inferior to the zygomatic arch through the masseter muscle; fluoroscopic imaging is used to guide the needle into the pterygopalatine fossa; imaging confirmed correct needle placement before anesthetic administration	Direct visualization of the needle position using fluoroscopy; it confirms accurate needle placement	It involves radiation exposure for both patients and operators; it is invasive and carries the risk of vascular injury and hematoma; it can damage the surrounding nerves

SPG: Sphenopalatine ganglion.

Table 2 Chronological summary of key systematic reviews and meta-analyses on postdural puncture headache management

Ref.	Type of review	Key focus	Included studies (n)	Key interventions	Main conclusion and finding
Basurto Ona et al[15], 2015	Cochrane review	Pharmacological treatment	13 RCTs	Caffeine, gabapentin, and theophylline	Evidence for the benefits of these drugs is limited owing to small, biased studies, although some drugs have shown promise
Barati-Boldaji et al[16], 2023	Meta-analysis	Aminophylline/theophylline	15 studies	Aminophylline, theophylline	They showed potential for treatment but not for prevention
Chang et al[17], 2021	Meta-analysis	GON block (treatment)	7 studies	Greater occipital nerve block	GONB is effective for short-term PDPH pain relief
Giaccari et al[18], 2021	Systematic review	Nerve blocks (treatment)	19 studies	SPG block, GONB, LON block	Peripheral nerve blocks are promising and safe options
Zhao et al[19], 2023	Bayesian network meta analysis	Pharmacological prevention	22 RCTs	Propofol, ondansetron, and amin	Propofol, ondansetron, and aminophylline were the most effective in reducing PDPH incidence
Dwivedi et al[20], 2023	Meta-analysis	SPG block (treatment)	9 RCTs	Trans-nasal SPG Block	The SPG block was effective for immediate pain relief compared to the controls, but the effect was short-lived
Alatni et al[3], 2024	Systematic review	Multi-modal (treatment and prevention)	38 studies	Pharmacologic, nerve blocks, EBP	Various effective strategies were summarized, and EBP was affirmed as the gold standard

RCT: Randomized controlled trial; GONB: Greater occipital nerve block; PDPH: Postdural puncture headache; SPG: Sphenopalatine ganglion; EBP: Epidural blood patch.

Table 3 Detailed efficacy and findings from included reviews

Ref.	Key focus	Main conclusion and finding	Key interventions with positive outcomes	Key interventions with no significant effect
Basurto Ona et al[15], 2015	Pharmacological treatment	However, evidence for the benefits was limited due to the small sample size and bias in the studies; some drugs were promising in reducing pain scores	Caffeine: Reduced PDPH persistence compared to placebo; gabapentin: Better VAS scores vs placebo/ergotamine; hydrocortisone: Better VAS scores than conventional treatment/placebo; theophylline: Better VAS scores than acetaminophen/conservative treatment	Sumatriptan and ACTH: No relevant effect on pain scores
Barati-Boldaji et al[16], 2023	Aminophylline/theophylline (Tx and prevention)	Therapeutic use significantly reduced pain scores (moderate evidence); prophylactic use did not significantly reduce the PDPH risk (very low evidence)	Aminophylline/theophylline: Effective for pain relief compared to placebo or conventional therapy	Aminophylline: Not effective for prevention
Chang et al[17], 2021	GON block (treatment)	GONB was effective for short-term pain relief at 1, 6, and 24 hours and reduced intervention failure	Greater occipital nerve block (GONB): Effective for pain relief; steroid co-administration may extend this effect	N/A
Giaccari et al[18], 2021	Nerve blocks (treatment)	Peripheral nerve blocks (SPG, GON, and LON) were effective, safe, and significantly reduced pain scores	SPG, GON, LON blocks: Effective analgesic options	N/A
Zhao et al[19], 2023	Pharmacological prevention (obstetric)	Propofol, ondansetron, and aminophylline were the most effective in reducing PDPH incidence; propofol and ondansetron also reduced PONV	Propofol (PPF), ondansetron (OND), and aminophylline (AMP) are effective; gabapentin/pregabalin (GBP/PGB): Effective at 48 hours	Dexamethasone, hydrocortisone: No superiority over placebo; no therapy reduced headache severity
Dwivedi et al[20], 2023	SPG block (treatment)	SPG block was effective for immediate, short-term pain relief (up to 6 hours) vs conservative treatment and lignocaine puffs	Transnasal SPG block: Effective for short-term relief	It was not superior to the sham or GON blocks; effects were not sustained beyond 6 hours
Alatni et al[3], 2024	Multi-modal (Tx and prevention)	Various effective strategies have been summarized, and EBP remains the gold standard; nerve blocks are effective and less invasive	Oral pregabalin and intravenous (IV) aminophylline are effective for the treatment and prevention of migraine headaches; IV Mannitol, IV hydrocortisone, neostigmine + atropine, SPG/GON blocks: Effective; fibrin glue, smaller needles: Effective prevention; EBP: Gold standard	Neuraxial morphine, epidural dexamethasone: Questionable for prevention

VAS: Visual analogue scale; GONB: Greater occipital nerve block; PDPH: Postdural puncture headache; ACTH: Adrenocorticotropic hormone; N/A: Not applicable; SPG: Sphenopalatine ganglion; LON: Lesser occipital nerve; PPF: Propofol; OND: Ondansetron; AMP: Aminophylline; GBP: Gabapentin; PGB: Pregabalin; PONV: Postoperative nausea and vomiting; EBP: Epidural blood patch.

Table 4 Consolidated efficacy summary of major postdural puncture headache interventions

Ref.	Intervention	Primary use	Efficacy for PDPH prevention	Efficacy for PDPH treatment	Key findings and notes	Common/notable side effects
Alatni et al[3], 2024; Barati-Boldaji et al[16], 2023	Aminophylline/theophylline	Treatment and prevention	Mixed (not recommended): A meta-analysis found no significant benefit of prophylaxis (very low evidence)	Effective (recommended): Significantly reduced pain scores (moderate evidence); this effect is enhanced when combined with dexamethasone	Considered a primary pharmacological option for treating established PDPH; the efficacy of prevention is not well supported	No significant adverse events were reported in the studies
Basurto Ona et al[15], 2015	Caffeine	Treatment	It is not typically used for prevention	Effective (recommended): Reduces the persistence of PDPH and the need for rescue interventions compared to placebo	A classic and well-established treatment for PDPH	Well tolerated; no major side effects were reported in the review
Alatni et al[3], 2024; Basurto Ona et al[15], 2015; Zhao et al[19], 2023	Gabapentin/pregabalin	Treatment and prevention	Effective (potential): Pregabalin has a preventive effect; gabapentin/pregabalin reduced incidence at 48 hours	Effective (recommended): Superior to placebo and ergotamine + caffeine in reducing pain scores over several days	Oral pregabalin has been highlighted as being particularly effective for both treatment and prevention	Generally well tolerated; sedation was mentioned but not quantitatively synthesized
Zhao et al[19], 2023	Ondansetron (OND)	Prevention	Effective (recommended): Significantly reduces the cumulative incidence of PDPH	Not assessed for treatment in these reviews	It also significantly reduces the incidence of postoperative nausea and vomiting (PONV)	It may induce migraine headaches in patients with a history of migraine (case reports)
Zhao et al[19], 2023	Propofol (PPF)	Prevention	Most effective (recommended): Ranked as the most effective prophylactic drug for reducing incidence	Not assessed for treatment in these reviews	Also significantly reduces the incidence of postoperative nausea and vomiting (PONV)	Sedation, diplopia, and tinnitus were mentioned in individual studies
Basurto Ona et al[15], 2015; Zhao et al[19], 2023	Corticosteroids (dexamethasone, hydrocortisone)	Treatment and prevention	Not effective: Dexamethasone did not show superiority in prevention (hydrocortisone did not show any significant prophylactic effects)	Effective for treatment: Hydrocortisone (IV) combined with conventional treatment led to better pain scores	Hydrocortisone is effective for treatment but not for prevention; the utility of dexamethasone remains questionable	No clinically significant adverse events were reported
Chang et al[17], 2021	Greater occipital nerve block (GONB)	Treatment	N/A	Effective (recommended): Provides significant short-term pain relief (1 hour, 6 hours, 24 hours) and reduces intervention failure	A feasible, less invasive alternative to EBP; steroid coadministration may prolong analgesic effects	No major adverse events were reported. Minor local discomfort
Dwivedi et al[20], 2023	Sphenopalatine ganglion block (SPGB)	Treatment	N/A	Effective (short-term): Superior to conservative care for immediate pain relief (up to 6 hours); not superior to sham or GONB	The effects are immediate but short-lived; it was not superior to the other nerve blocks	Nasal discomfort, throat numbness, and unpleasant taste (minor and transient)
Alatni et al[3], 2024	Epidural blood patch (EBP)	Treatment	N/A	Highly effective (gold standard): The ultimate solution for patients failing medical therapy	It rapidly decreases headache intensity; approximately 20% may require a second procedure; it is more invasive than pharmacological or nerve block options	Risks associated with neuraxial procedures (e.g., infection, repeat dural puncture)
Alatni et al[3], 2024	Fibrin glue	Prevention	Effective (promising): Significantly reduced PDPH incidence and duration in the reviewed evidence	N/A	A novel preventive strategy has been noted for its promising safety and affordability	Not explicitly stated; however, the reviewed evidence noted a good safety profile

PDPH: Postdural puncture headache; OND: Ondansetron; PPF: Propofol; PONV: Postoperative nausea and vomiting; N/A: Not applicable; GONB: Greater occipital nerve block; EBP: Epidural blood patch; SPG: Sphenopalatine ganglion; SPGB: Sphenopalatine ganglion block.