Objective:

Illustrate a case of successful use of SPG block for short term migraine prophylaxis during pregnancy in a patient with intractable chronic migraine. 

Background:

Options for management of intractable chronic migraine during pregnancy are limited. SPG block with lidocaine presents an easy option with minimal potential risk as a short term preventative treatment during pregnancy. 

Design/Methods:

Patient was a 37-year-old female with PMH of depression, asthma, B12 deficiency, and insomnia who presented with intractable migraine during pregnancy. She was on Bupropion and Trazodone for mood and insomnia. She averaged four migraine days per week pre-pregnancy. She had initial improvement in migraine frequency shortly after conception but at week 12 had sharp uptick with severe migraines requiring two emergency department visits for treatment of migraine. She failed multiple different preventative treatments in different pharmacologic categories as well as a neuromodulatory device. Severe migraines persisted despite continued treatment with onabotulinumtoxinA and peripheral nerve blocks with lidocaine. We performed bilateral SPG block with administration of viscous 2% lidocaine, delivered intranasally with a cotton tip applicator targeting the posterior middle nasal turbinate. 

Results:

Patient reported immediate reduction of pain with sustained relief for 1.5 weeks. We repeated the procedure every two weeks through remainder of pregnancy and patient remained largely migraine free. She delivered the baby preterm at 29 weeks 4 days. Obstetrics and neonatal teams unable to identify the direct cause of preterm labor.  

Conclusions:

We report a case where SPG block used successfully for short term migraine treatment during pregnancy. More data is required to establish its safety and effectiveness.