Brazilian Journal of Anesthesiology
Brazilian Journal of Anesthesiology
Systematic Review

Trans-nasal sphenopalatine ganglion block for post-dural puncture headache management: a meta-analysis of randomized trials

Bloqueio transnasal do gânglio esfenopalatino para tratamento de cefaleia pós-punção dural: uma meta-análise de ensaios randomizados

Priyanka Dwivedi, Pratibha Singh, Tejas K. Patel, Vijeta Bajpai, Ankita Kabi, Yashpal Singh, Santosh Sharma, Surekha Kishore

Downloads: 5
Views: 576


To evaluate the efficacy and safety of trans-nasal Sphenopalatine Ganglion (SPG) block over other treatments for Post-Dural Puncture Headache (PDPH) management.

A systematic literature search was conducted on databases for Randomized Controlled Trials (RCTs) comparing trans-nasal SPG blockade for the management of PDPH over other treatment modalities. All outcomes were pooled using the Mantel-Haenszel method and random effect model. Analyses of all outcomes were performed as a subgroup based on the type of control interventions (conservative, intranasal lignocaine puffs, sham, and Greater Occipital Nerve [GON] block). The quality of evidence was assessed using the GRADE approach.

After screening 1748 relevant articles, 9 RCTs comparing SPG block with other interventions (6 conservative treatments, 1 sham, 1 GON and 1 intranasal lidocaine puff) were included in this meta-analysis. SPG block demonstrated superiority over conservative treatment in pain reduction at 30 min, 1 h, 2 h, 4 h after interventions and treatment failures with “very low” to “moderate” quality of evidence. The SPG block failed to demonstrate superiority over conservative treatment in pain reduction beyond 6 h, need for rescue treatment, and adverse events. SPG block demonstrated superiority over intranasal lignocaine puff in pain reduction at 30 min, 1 h, 6 h, and 24 h after interventions. SPG block did not show superiority or equivalence in all efficacy and safety outcomes as compared to sham and GON block.

Very Low to moderate quality evidence suggests the superiority of SPG block over conservative treatment and lignocaine puff for short-term pain relief from PDPH.

PROSPERO Registration


Post-dural puncture headache Sphenopalatine ganglion block Headache Pain management Conservative treatment



Avaliar a eficácia e segurança do bloqueio transnasal do gânglio esfenopalatino (BTGEP) em relação a outros tratamentos para tratamento da cefaleia pós-punção dural (CPPD).


Uma pesquisa sistemática da literatura foi realizada em bancos de dados de ensaios clínicos randomizados (ECR) comparando o bloqueio transnasal do GEP para o manejo da CPPD em relação a outras modalidades de tratamento. Todos os resultados foram agrupados usando o método Mantel-Haenszel e modelo de efeito aleatório. As análises de todos os resultados foram realizadas como um subgrupo com base no tipo de intervenções de controle (conservador, inalações intranasais de lidocaína, simulação e bloqueio do Nervo Occipital Maior [NOM]). A qualidade da evidência foi avaliada utilizando a abordagem GRADE.


Após a triagem de 1.748 artigos relevantes, 9 ECRs comparando o bloqueio do GEP com outras intervenções (6 tratamentos conservadores, 1 placebo, 1 bloqueio NOM e 1 injeção intranasal de lidocaína) foram incluídos nesta meta-análise. O bloqueio GEP demonstrou superioridade sobre o tratamento conservador na redução da dor 30 min, 1 h, 2 h, 4 h após intervenções e falhas de tratamento com qualidade de evidência “muito baixa” a “moderada”. O bloqueio GEP não conseguiu demonstrar superioridade sobre o tratamento conservador na redução da dor além de 6 horas, necessidade de tratamento de resgate e eventos adversos. O bloqueio GEP demonstrou superioridade sobre a injeção intranasal de lidocaína na redução da dor 30 minutos, 1 hora, 6 horas e 24 horas após as intervenções. O bloqueio GEP não mostrou superioridade ou equivalência em todos os resultados de eficácia e segurança em comparação com o bloqueio simulado e o bloqueio NOM.


Evidências de qualidade muito baixa a moderada sugerem a superioridade do bloqueio SPG sobre o tratamento conservador e a inalação de lidocaína para alívio da dor em curto prazo da CPPD.




Cefaléia pós-punção dural; Bloqueio do gânglio esfenopalatino; Dor de cabeça; Manejo da dor; Tratamento conservador


1. Bier A. Versuche uber Cocainisirung des R € uckenmarkes. Deut- € sche Zeitschrift fur Chirurgie. 1899;51:361 € −9.

2. Oedit R, van Kooten F, Bakker SLM, Dippel DWJ. Efficacy of the epidural blood patch for the treatment of post lumbar puncture headache BLOPP: a randomised, observer-blind, controlled clinical trial [ISRCTN 71598245]. BMC Neurol. 2005;5:12.

3. Kiki I, Gundogdu M, Alici HA, Yildirim R, Bilici M. A Simple, Safe and Effective Approach to Prevent Postdural Puncture Headache: Epidural Saline Injection. Eurasian J Med. 2009;41:175.

4. Kwak KH. Postdural puncture headache. Korean J Anesthesiol. 2017;70:136−43.

5. Ona XB, Osorio D, Cosp XB. Drug therapy for treating post-dural puncture headache. Cochrane Database Syst Rev. 2015;2015: CD007887.

6. Bucklin BA, Hawkins JL, Anderson JR, Ullrich FA. Obstetric anesthesia workforce survey: twenty-year update. Anesthesiology. 2005;103:645−53.

7. Paech MJ, Doherty DA, Christmas T, Wong CA. The volume of blood for epidural blood patch in obstetrics: a randomized, blinded clinical trial. Anesth Analg. 2011;113:126−33.

8. Van Kooten F, Oedit R, Bakker SLM, Dippel DWJ. Epidural blood patch in post dural puncture headache: a randomised, observer-blind, controlled clinical trial. J Neurol Neurosurg Psychiatry. 2008;79:553−8.

9. Ghaleb A. Postdural puncture headache. Anesthesiol Res Pract. 2010;2010:102967.

10. Cohen S, Sakr A, Katyal S, Chopra D. Sphenopalatine ganglion block for postdural puncture headache. Anaesthesia. 2009;64:574−5.

11. Kent S, Mehaffey G. Transnasal sphenopalatine ganglion block for the treatment of postdural puncture headache in obstetric patients. J Clin Anesth. 2016;34:194−6.

12. Akyol F, Binici O, Kuyrukluyildiz U, Karabakan G. Ultrasoundguided bilateral greater occipital nerve block for the treatment of post-dural puncture headache. Pak J Med Sci. 2015;31:1−5.

13. Katz D, Beilin Y. Review of the Alternatives to Epidural Blood Patch for Treatment of Postdural Puncture Headache in the Parturient. Anesth Analg. 2017;124:1219−28.

14. Binfalah M, Alghawi E, Shosha E, Alhilly A, Bakhiet M. Sphenopalatine Ganglion Block for the Treatment of Acute Migraine Headache. Pain Res Treat. 2018;2018:2516953.

15. Robbins MS, Robertson CE, Kaplan E, et al. The Sphenopalatine Ganglion: Anatomy, Pathophysiology, and Therapeutic Targeting in Headache. Headache. 2016;56:240−58.

16. Cohen S, Trnovski S, Zada Y. A new interest in an old remedy for headache and backache for our obstetric patients: a sphenopalatine ganglion block. Anaesthesia. 2001;56:606−7.

17. Kent S, Mehaffey G. Transnasal sphenopalatine ganglion block for the treatment of postdural puncture headache in the ED. Am J Emerg Med. 2015;33. 1714.e1-1714.e2.

18. Cohen S, Levin D, Mellender S, et al. Topical Sphenopalatine Ganglion Block Compared With Epidural Blood Patch for Postdural Puncture Headache Management in Postpartum Patients: A Retrospective Review. Reg Anesth Pain Med. 2018;43:880−4.

19. Takmaz SA, Karaoglan M, Baltac{ B, Bektas M, Ba ¸ sar H. Trans- ¸ nasal Sphenopalatine Ganglion Block for Management of Postdural Puncture Headache in Non-Obstetric Patients. J Nippon Med Sch. 2021;88:291−5.

20. Ho KWD, Przkora R, Kumar S. Sphenopalatine ganglion: block, radiofrequency ablation and neurostimulation - a systematic review. J Headache Pain. 2017;18:118.

21. Hung KC, Chen JY, Ho CN, Sun CK. Use of sphenopalatine ganglion block in patients with postdural puncture headache: a pilot meta-analysis. Br J Anaesth. 2021;126:e25−7.

22. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71.

23. Mean Variance Estimation [Internet]. [cited 2023 Mar 22]. Available from:»tongt/papers/ median2mean.html.

24. Luo D, Wan X, Liu J, Tong T. Optimally estimating the sample mean from the sample size, median, mid-range, and/or midquartile range. Stat Methods Med Res. 2018;27:1785−805.

25. Wan X, Wang W, Liu J, Tong T. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol. 2014;14:135.

26. Dwivedi P, Patel TK, Bajpai V, Singh Y, Tripathi A, Kishore S. Efficacy and safety of intranasal ketamine compared with intranasal dexmedetomidine as a premedication before general anesthesia in pediatric patients: a systematic review and metaanalysis of randomized controlled trials. Can J Anesth. 2022;69:1405−18.

27. Sterne JAC, Savovic J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898.

28. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336:924−6.

29. GRADEpro [Internet]. [cited 2023 Jan 9]. Available from:

30. Abotaleb AM, ElSharkawy MS, Almawardy HG. Bilateral sphenopalatine ganglion block with adrenaline additive for post-dural puncture headache in orthopedic patients: A randomized controlled trial. Egypt J Anaesth. 2022;38:305−9.

31. Bohara C, Maharjan R, Regmi S, Regmi G, Singh AK, Shrestha A. Sphenopalatine Ganglion Block versus Conservative Management for Post Dural Puncture Headache in Cesarean Section. Nepal J Health Sci. 2022;2:22−6.

32. Jespersen MS, Jaeger P, Ægidius KL, et al. Sphenopalatine ganglion block for the treatment of postdural puncture headache: a randomised, blinded, clinical trial. Br J Anaesth. 2020;124:739−47.

33. Kumar R, Verma VK, Swati Prasad C. Comparative evaluation of conservative management and sphenopalatine ganglion block for postdural puncture headache: A randomized controlled trial. Bali J Anesthesiol. 2020;4:183.

34. Mowafi MM, Abdelrazik RA. Efficacy and efficiency of sphenopalatine ganglion block for management of post-dural puncture headache in obstetric patients: a randomized clinical trial. AinShams J Anesthesiol. 2022;14:1−8.

35. Nazir N, Saxena A, Asthana U. Efficacy and Safety of Trans-nasal Sphenoid Ganglion Block in Obstetric Patients With Post-dural Puncture Headache: A Randomized Study. Cureus. 2021;13: e20387.

36. Puthenveettil N, Rajan S, Mohan A, Paul J, Kumar L. Sphenopalatine ganglion block for treatment of post-dural puncture headache in obstetric patients: An observational study. Indian J Anaesth. 2018;62:972−7.

37. Y{lmaz M, K{l{c Y ¸ {lmaz V, et al. Transnasal Sphenopalatine ganglion block for treatment of post-dural puncture headache in obstetric population. South Clin Ist Euras. 2020;31:335−9.

38. Youssef HA, Abdel-Ghaffar HS, Mostafa MF, Abbas YH, Mahmoud AO, Herdan RA. Sphenopalatine Ganglion versus Greater Occipital Nerve Blocks in Treating Post-Dural Puncture Headache after Spinal Anesthesia for Cesarean Section: A Randomized Clinical Trial. Pain Physician. 2021;24:E443−51.

39. Abdelhaleem Abdelhaleem NF. Verification of Sphenopalatine Ganglion Block Success Using Transcranial Doppler in Management of Patients with Postdural. Pain Physician. 2021;24: E661−8.

40. Preet Patel. Sphenopalatine Ganglion Block Effective and Safe for Postdural Puncture Headache [Internet]. In: American Academy of Pain Medicine 32nd Annual Meeting; 2016. [cited 2023 Jan 9]. Available from:

41. Costa A, Pucci E, Antonaci F, et al. The effect of intranasal cocaine and lidocaine on nitroglycerin-induced attacks in cluster headache. Cephalalgia. 2000;20:85−91.

42. Cady RK, Saper J, Dexter K, Cady RJ, Manley HR. Long-term efficacy of a double-blind, placebo-controlled, randomized study for repetitive sphenopalatine blockade with bupivacaine vs. saline with the Tx360 device for treatment of chronic migraine. Headache. 2015;55:529−42.

43. Cady R, Saper J, Dexter K, Manley HR. A double-blind, placebocontrolled study of repetitive transnasal sphenopalatine ganglion blockade with tx360() as acute treatment for chronic migraine. Headache. 2015;55:101−16.

44. Crespi J, Bratbak D, Dodick D, et al. Measurement and implications of the distance between the sphenopalatine ganglion and nasal mucosa: a neuroimaging study. J Headache Pain. 2018;19:14.

45. Iwanaga JOE, Wilson C, Simonds E, et al. Clinical Anatomy of Blockade of the Pterygopalatine Ganglion: Literature Review and Pictorial Tour Using Cadaveric Images. Kurume Med J. 2018;65:1−5.

46. Piagkou MN, Demesticha T, Troupis T, et al. The pterygopalatine ganglion and its role in various pain syndromes: from anatomy to clinical practice. Pain Pract. 2012;12:399−412.

47. Nair AS, Rayani BK. Sphenopalatine ganglion block for relieving postdural puncture headache: technique and mechanism of action of block with a narrative review of efficacy. Korean J Pain. 2017;30:93−7.

48. Dubey P, Dubey PK. Intranasal lignocaine spray for sphenopalatine ganglion block for postdural puncture headache. Saudi J Anaesth. 2018;12:364−5.

49. Gayathri G, Karthik K, Saravanan R, Meshach M, Pushparani A. A randomized control study to assess the efficacy of the sphenopalatine ganglion block in patients with post dural puncture headache. Saudi J Anaesth. 2022;16:401.

50. Bhargava T, Kumar A, Rastogi A, Srivastava D, Singh T. A Simple Modification of Sphenopalatine Ganglion Block for Treatment of Postdural Puncture Headache: A Case Series. Anesth Essays Res. 2021;15:143.

51. Pai R, Vas L. Transnasal Approach to Sphenopalatine Ganglion Blockade: An Alternate Technique. Indian J Palliat Care. 2015;21:360−1.

52. Wasserman RA, Schack T, Moser SE, Brummett CM, Cooper W. Facial Temperature Changes Following Intranasal Sphenopalatine Ganglion Nerve Block. J Nat Sci. 2017;3:1−3.

Submitted date:

Accepted date:

64b5b45da953954e0e0e3943 rba Articles
Links & Downloads

Braz J Anesthesiol

Share this page
Page Sections