Sphenopalatine Ganglion Block for Post-Dural Puncture Headache
Evidence does not support the routine use of sphenopalatine ganglion blocks for treating post-dural puncture headache (PDPH). 1
Guideline Recommendations
The most recent and authoritative consensus guidelines from 2023 explicitly state that sphenopalatine ganglion blocks should not be routinely used to treat PDPH (evidence grade: I; level of certainty: low). 1 This recommendation comes from a multisociety international working group that comprehensively reviewed the available evidence and found insufficient support for this intervention.
Supporting Research Evidence
The lack of guideline support is reinforced by the highest quality randomized controlled trial on this topic:
A 2020 blinded RCT comparing sphenopalatine ganglion block with local anesthetic versus placebo (saline) found no statistically significant difference in pain reduction at 30 minutes (median difference: 5 mm on VAS; 95% CI: -14 to 21; P=0.53). 2
Importantly, both groups showed substantial pain reduction and 50% of the local anesthetic group still required epidural blood patch compared to 45% in the placebo group (P=0.76), suggesting the observed benefit was not attributable to the local anesthetic itself. 2
A comparative trial found that while sphenopalatine ganglion blocks did reduce pain, greater occipital nerve blocks achieved clinically significant pain reduction (NRS <4) earlier than sphenopalatine blocks, though both were eventually similar after 3 hours. 3
Clinical Context and Practical Considerations
While case reports and case series describe successful use of sphenopalatine ganglion blocks for PDPH 4, 5, 6, these lower-quality evidence sources cannot override the guideline recommendations and the negative RCT findings.
Additional concern during COVID-19: Nasal sphenopalatine ganglion block is considered a potential aerosol-generating procedure and should be avoided in patients with suspected or confirmed COVID-19 due to transmission risk to healthcare workers. 1
Recommended Treatment Algorithm for PDPH
Instead of sphenopalatine ganglion blocks, follow this evidence-based approach:
First-line conservative management:
- Multimodal analgesia with acetaminophen and NSAIDs (evidence grade: B) 1, 7
- Caffeine up to 900 mg/day in first 24 hours (200-300 mg if breastfeeding) (evidence grade: B) 1, 7
- Adequate oral hydration; IV fluids only if oral intake inadequate (evidence grade: C) 1, 7
- Short-term opioids if multimodal analgesia fails (evidence grade: C) 1
Procedural interventions if conservative measures fail:
- Greater occipital nerve blocks may be offered for PDPH after spinal anesthesia with 22G needles, though headache may recur requiring epidural blood patch (evidence grade: C; level of certainty: moderate) 1, 7
- Epidural blood patch remains the definitive treatment for severe or refractory PDPH 1, 7, 5
Key Pitfall to Avoid
Do not be misled by the placebo effect or natural resolution of PDPH when considering sphenopalatine ganglion blocks—the RCT demonstrated that approximately half of patients improved regardless of whether they received local anesthetic or saline, indicating substantial placebo response and natural disease course. 2