Therapeutic Epidural Patch Versus Pain Block in the Midface for Headache

The sphenopalatine nerve block has been used to treat headaches. Patients have headaches after epidural access from post dural puncture. We need to know if sphenopalatine nerve block will help the patient with the headache.

• Epidural Blood Patch (Device): A device: 17 gauge Tuohy needle will be placed to the epidural space using the loss of resistance technique. Once positioned a sterile stylet will be replaced within the needle to maintain the sterility of the epidural space. A tourniquet may be used to identify a peripheral venous site, which will be sterilely prepped with betadine x3 and then chloraprep. Venipuncture will be performed with a device: 20gauge or larger needle. 20mL of blood will be aspirated in a sterile system into an appropriately sized syringe. After sterile transfer, this autologous blood will be slowly injected into the epidural space.
• Sphenopalatine Ganglion Block (Drug): The drug: 5% lidocaine ointment, a local anesthetic, will be applied to the end of a device: long channeled cotton tipped applicator inserted into both nares and placed over the mucosa in the area of posterior aspect of the middle ethmoid, toward the presumed anatomic location of the sphenopalatine ganglion, evidenced by a slight resistance at the appropriate depth. 5mL of drug: 1% lidocaine solution will then be injected into the hollow shaft of the device: applicator and allowed to topically anesthetize the ganglion by gravity flow for 30 minutes.

Primary outcomes

• Number of Headaches With a VAS Score >8/10 Prior to Initiation of Either Therapy [Prior to initiation of therapy (Epidural blood patch vs Sphenopalatine Ganglion Block).]: Outcome measure will entail recording patient self-reported pain scores to quantify the level of headache pain using the Visual analog scale, meaning 0 - No pain, 1-3 - Mild Pain, 4-6 - Moderate Pain, 7-10 - Severe Pain, by way of in person assessment by pain questionnaire just prior to initiation of either therapy (Epidural blood patch vs Sphenopalatine Ganglion Block).
• Number of Participants With a Headache Vas 8/10 at 30 Minutes Following Either Therapy. [At 30 minutes following either therapy.]: Self-reported pain scores to quantify the level of headache pain using the Visual analog scale (as defined within the description of outcome 1 above) by way of in person assessment by pain questionnaire at 30 minutes following either therapy (Epidural blood patch vs Sphenopalatine Ganglion Block).
• Number of Participants With a Headache Vas 8/10 at 60 Minutes Following Either Therapy. [At 60 minutes following either therapy.]: Self-reported pain scores to quantify the level of headache pain using the Visual analog scale (as defined within the description of outcome 1 above) by way of in person assessment by pain questionnaire at 60 minutes following either therapy (Epidural blood patch vs Sphenopalatine Ganglion Block).

Sex: All, ages: 13 Years to 92 Years, accepts healthy volunteers

Inclusion Criteria:

* Males and females ages 13-92
* Subjects have medical diagnosis of PDPH and require treatment
* Subjects who signed consent/assent

Exclusion Criteria:

* <13 years of age
* Pregnancy
* Subjects with heart failure
* Subjects already being treated with lidocaine patch or other vehicle for chronic pain
* Non-english speaking subjects
* Subjects with platelets <100,000
* Subjects that are septic
* Subjects with an allergy to lidocaine
* Subjects with known nasal polyps
* Subjects with recent neurological event
* Subjects on anticoagulant therapy
* Subjects that received prior therapy with SPG block or EBP

Participant flow

Outcome results

• Number of Headaches With a VAS Score >8/10 Prior to Initiation of Either Therapy (Primary), Number, headache with VAS >8/10: Epidural Blood Patch Group 1; Sphenopalatine Ganglion Block Group 1
• Number of Participants With a Headache Vas 8/10 at 30 Minutes Following Either Therapy. (Primary), Count of participants, Participants: Epidural Blood Patch Group 1; Sphenopalatine Ganglion Block Group 1
• Number of Participants With a Headache Vas 8/10 at 60 Minutes Following Either Therapy. (Primary), Count of participants, Participants: Epidural Blood Patch Group 1; Sphenopalatine Ganglion Block Group 0 (p <0.01)

Adverse events

Time frame: 48 hours

• Study Protocol and Statistical Analysis Plan (PDF, 2021-10-05)
• Informed Consent Form (PDF, 2021-10-13)

• William Grubb, DDS, MD, Principal investigator, Rutgers Robert Wood Johnson Medical School