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Alternative Migraine Treatments
We’ve all seen that patient. The one who has tried EVERYTHING for migraines and nothing works. They had too many side effects on triptans, topamax, verapamil, or propranolol. Acupuncture, massage, oxygen, and cryohelmets were not effective. You may know there are some injections that can be done, but perhaps your patient doesn’t have insurance and can’t afford to see a neurologist.
Prior to referring your patient out, you may be able to try some of these injections in the office.
First and foremost, it’s important to find out if there are any specific triggers for the patient’s headaches. Some people find that stress and tension seem to cause neck pain and trigger migraines. For these people, you can start by trying simple trigger point injections into the cervical paraspinal muscles once every few weeks until their headaches diminish. You can use 0.5-1 cc of 1% plain lidocaine in the points of maximal tenderness, but some like to use a little steroid, such as Kenalog, as well.
If you want to go even further you can do a simple occipital nerve block procedure which involves injecting lidocaine over the occipital nerve to block pain.
Here is a great video on how to do this procedure.
In combination with cervical trigger point injections, occipital nerve blocks work very well for migraines associated with cervical muscle spasms. Some patients respond well even if they don’t have associated neck tension, so it is worth trying if their migraines are intractable.
Three other nerve blocks may be helpful for more traditional migraines or frontal headaches. These are the supraorbital nerve block, supratrochlear nerve block, and sphenopalatine nerve block.
The supraorbital and supratrochlear blocks are generally done together. The supraorbital block is easiest and sometimes useful on its own. For this block, you inject about 1 to 1.5 cc of 1% lidocaine just over the supraorbital notch.
The following video is a great overview of these injections for migraines. This surgeon also does a trigeminal nerve block, which may also be useful but not as common.
On a side note, keep in mind you can do a simple supraorbital block for forehead lacerations.
Here is a video example of this.
Lastly, you can try a sphenopalatine block. There are many ways to do this block.
The easiest (but also the most expensive) way to do this is to use a special catheter.
There are 3 devices: Sphenocath ($670.50 for a 10 pack), the Allevio ($625.00 for a 5 pack), and the TX360 used in the MiRx protocol ($650.00 for a 10 pack). The nice thing about these catheters is that you can access more precisely the correct spot over top of the ganglion every time. When setting your price, be sure to cover the cost of the catheter, lidocaine, and a small markup for credit card processing. Dr. Blackwell at Clarity Direct charges $90 per SPG block, which patients are happy to pay as they typically experience about 6 weeks of relief. Although not ideal, catheters may be reused up to 4 times before they stop working. Dr. Blackwell does not charge for blocks when a catheter is reused. Make sure to clean it well by soaking it in alcohol after use and clean it before keeping it in the original box for the next use.
Here is a video of Dr. Kissi Blackwell, a DPC Alliance member demonstrating.
You can also use a very inexpensive angiocath on the tip of a syringe, but you can potentially miss the spot since they are not very long, but they are much less expensive than the special catheters and worth a try.
Here is a video showing an ER doctor doing this for acute migraines. He states in the video they last just a few days and he does them weekly or biweekly for patients, which possibly means that this technique is not quite as good at reaching the ganglion as those who have had blocks using the procedure-specific catheters typically report 6 weeks of relief or more.
If you would like to learn a little more, this is a really nice overview of the sphenopalatine block and the premise behind it linked here.
* All videos linked in this article are provided solely as an educational reference for DPC Alliance members.
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Alternative Migraine Treatments
We’ve all seen that patient. The one who has tried EVERYTHING for migraines and nothing works. They had too many side effects on triptans, topamax, verapamil, or propranolol. Acupuncture, massage, oxygen, and cryohelmets were not effective. You may know there are some injections that can be done, but perhaps your patient doesn’t have insurance and can’t afford to see a neurologist.
Prior to referring your patient out, you may be able to try some of these injections in the office.
First and foremost, it’s important to find out if there are any specific triggers for the patient’s headaches. Some people find that stress and tension seem to cause neck pain and trigger migraines. For these people, you can start by trying simple trigger point injections into the cervical paraspinal muscles once every few weeks until their headaches diminish. You can use 0.5-1 cc of 1% plain lidocaine in the points of maximal tenderness, but some like to use a little steroid, such as Kenalog, as well.
If you want to go even further you can do a simple occipital nerve block procedure which involves injecting lidocaine over the occipital nerve to block pain.
Here is a great video on how to do this procedure.
In combination with cervical trigger point injections, occipital nerve blocks work very well for migraines associated with cervical muscle spasms. Some patients respond well even if they don’t have associated neck tension, so it is worth trying if their migraines are intractable.
Three other nerve blocks may be helpful for more traditional migraines or frontal headaches. These are the supraorbital nerve block, supratrochlear nerve block, and sphenopalatine nerve block.
The supraorbital and supratrochlear blocks are generally done together. The supraorbital block is easiest and sometimes useful on its own. For this block, you inject about 1 to 1.5 cc of 1% lidocaine just over the supraorbital notch.
The following video is a great overview of these injections for migraines. This surgeon also does a trigeminal nerve block, which may also be useful but not as common.
On a side note, keep in mind you can do a simple supraorbital block for forehead lacerations.
Here is a video example of this.
Lastly, you can try a sphenopalatine block. There are many ways to do this block.
The easiest (but also the most expensive) way to do this is to use a special catheter.
There are 3 devices: Sphenocath ($670.50 for a 10 pack), the Allevio ($625.00 for a 5 pack), and the TX360 used in the MiRx protocol ($650.00 for a 10 pack). The nice thing about these catheters is that you can access more precisely the correct spot over top of the ganglion every time. When setting your price, be sure to cover the cost of the catheter, lidocaine, and a small markup for credit card processing. Dr. Blackwell at Clarity Direct charges $90 per SPG block, which patients are happy to pay as they typically experience about 6 weeks of relief. Although not ideal, catheters may be reused up to 4 times before they stop working. Dr. Blackwell does not charge for blocks when a catheter is reused. Make sure to clean it well by soaking it in alcohol after use and clean it before keeping it in the original box for the next use.
Here is a video of Dr. Kissi Blackwell, a DPC Alliance member demonstrating.
You can also use a very inexpensive angiocath on the tip of a syringe, but you can potentially miss the spot since they are not very long, but they are much less expensive than the special catheters and worth a try.
Here is a video showing an ER doctor doing this for acute migraines. He states in the video they last just a few days and he does them weekly or biweekly for patients, which possibly means that this technique is not quite as good at reaching the ganglion as those who have had blocks using the procedure-specific catheters typically report 6 weeks of relief or more.
If you would like to learn a little more, this is a really nice overview of the sphenopalatine block and the premise behind it linked here.
* All videos linked in this article are provided solely as an educational reference for DPC Alliance members.