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TREATMENT OF CHRONIC MIGRAINE WITH INFILTRATIONS AND
SPHENOPALATINE BLOCK: CASE REPORT
Maykon Hayak Pereira Lopes1
Abstract: Chronic migraine is a debilitating condition that affects millions of people globally,
signicantly impacting patients’ quality of life and productivity. This case report describes
the management of a 42-year-old woman diagnosed with chronic migraine for 20 years, with no
relevant comorbidities. The patient experienced 20 monthly episodes of mild pain and 4 of severe
pain. Treatment included trigger point inltrations with a solution of 0.25% levobupivacaine, 25%
glucose, and 6.5 mg of dexamethasone, totaling 10 mL, and nasal sphenopalatine block with the same
solution. Pharmacological treatment was supplemented with atenolol 25 mg daily. The inltration and
sphenopalatine block protocol was repeated after 21 days. After three months, a signicant reduction
in the frequency and intensity of attacks was observed, suggesting that the combination of inltrations
and pharmacological therapy is an effective strategy in the management of chronic migraine.
Keywords: chronic migraine; pain control; inltration; sphenopalatine block; levobupivacaine;
dexamethasone.
1 Anesthesiologist certied by the Brazilian Society of Anesthesiology, he graduated in Medi-
cine from the University Center of Espírito Santo (UNESC) and completed a Medical Residency in
Anesthesiology. He also works as a Medical Residency Teacher in Anesthesiology at HMSJ.
Introduction
Chronic migraine is a common and disabling condition, characterized by frequent and
prolonged headache attacks, often accompanied by symptoms such as nausea, vomiting, and
photophobia (Silva AG, et al, 2020). Management involves a multimodal approach, combining
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pharmacological therapies and local interventions, such as inltrations and nerve blocks, which have
been shown to be effective in reducing pain and seizure frequency (Häuser W, et al, 2018).
Patient Information
A 42-year-old female patient with no associated comorbidities was diagnosed with chronic
migraine 20 years ago. He reported pulsatile pain lasting between 4 and 72 hours, accompanied by
nausea and photophobia (Goadsby PJ, et al, 2002). She had a pattern of 20 monthly episodes of mild
pain and 4 episodes of severe pain, with a signicant impact on her quality of life and professional
performance. Family history: mother with systemic arterial hypertension, father with systemic arterial
hypertension and sister with migraine (Goadsby PJ, et al, 2002).
Clinical Findings
Crises have intensied in the last ve years, with an increasingly lower response to
conventional pharmacological treatments (Häuser W, et al, 2018). The neurological evaluation did
not show focal decits, and the complementary tests were within the normal range, reinforcing the
diagnosis of chronic migraine without aura (Goadsby PJ, et al, 2002).
Diagnostic Evaluation
Based on the diagnostic criteria of the International Headache Society (IHS), the patient met
the requirements for chronic migraine without aura. Differential diagnoses, such as cluster headache
or tension headache, were ruled out by clinical evaluation and normal imaging tests (Goadsby PJ, et
al, 2002).
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Therapeutic Intervention
Treatment included inltrations at trigger points with 0.25% levobupivacaine solution, 25%
glucose, and 6.5 mg dexamethasone (Sabbagh MN, et al, 2019). 20 trigger points were inltrated,
applying 0.5 mL per point, totaling 10 mL. Sphenopalatine block was performed nasally, using the
same solution applied with an embedded swab, kept in contact for 10 minutes. After 21 days, the same
protocol was repeated, aiming to enhance pain control (Sabbagh MN, et al, 2019). At the same time,
prophylactic treatment with atenolol 25 mg/day was initiated (D’Amico D, et al, 2015).
Monitoring and Results
The patient attended the rst consultation on March 15, 2024, reporting about 20 episodes
of mild migraine and 5 intense attacks in the last month. A protocol was initiated with inltrations in
trigger points and sphenopalatine ganglion blockade, associated with the use of atenolol 25 mg/day.
After 21 days (April 5, 2024), there was a partial reduction in symptoms, with 15 mild
episodes and 3 intense crises, and the initial protocol was repeated.
In the rst month (April 15, 2024), there were 10 mild episodes and 1 intense crisis.
In the second month (May 15, 2024), only 5 mild episodes and 1 intense crisis.
At the end of the third month (June 15, 2024), only 2 mild episodes and no intense seizures
were observed.
This result demonstrates a progressive and sustained response to the multimodal treatment
instituted, with a reduction of approximately 90% in the total frequency of seizures and complete
elimination of intense seizures. The therapeutic response was highly positive, with a signicant
improvement in quality of life and a signicant reduction in the use of analgesics.
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Discussion
Studies demonstrate the efcacy of trigger point inltrations and nerve blocks in the
management of chronic migraine, especially when combined with systemic prophylactic therapies
(Häuser W, et al, 2018). Local anesthetics, such as levobupivacaine, associated with corticosteroids,
such as dexamethasone, promote local anti-inammatory effect and reduce central sensitization
(Häuser W, et al, 2018). In addition, glycerol can act as an osmotic neuromodulator and as an aid in
prolotherapy. In a randomized clinical trial, a nasal spray containing glycerol applied to the nasal mucosa
formed a protective, osmotic lm that signicantly reduced the frequency and intensity of migraine
attacks (Ferrante T, et al, 2018). In parallel, dextrose prolotherapy has been shown to be effective in
reducing the frequency, intensity, and duration of seizures in patients with tension headaches and
migraines, with improvement maintained up to 22 months after treatment (Rabago D, et al, 2017).
Sphenopalatine block, described by Sabbagh et al. (2019), has a direct impact on parasympathetic
bers and the trigeminal nerve, involved in the pathophysiology of migraine (Tassorelli C, et al, 2017).
Beta-blockers such as atenolol are also validated in prophylaxis, with proven benet in reducing
the frequency and intensity of seizures (Silva AG, et al, 2020). The case presented here reinforces
the importance of a multimodal approach, combining local therapies (inltrations and blockade),
osmotic neuromodulation via glycerol and regenerative support by prolotherapy, added to systematic
prophylactic therapy, to achieve effective and lasting control of chronic migraine.
Patient Perspective
The patient described a relevant transformation in her routine after the beginning of
treatment, highlighting a signicant reduction in the limitations imposed by pain and greater freedom
to resume daily activities previously compromised by crises. She reported improved physical and
emotional disposition, a feeling of greater control over the disease and a positive impact on her social
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and professional life. He also emphasized the ease of adherence to the proposed protocol and high
satisfaction with the results achieved.
References
Silva AG, et al. Management of chronic migraine: current treatments and future directions. Ther Adv
Chronic Dis. 2020;11:2040622320901243.
Goadsby PJ, et al. Pathophysiology of migraine. J Neurol Neurosurg Psychiatry. 2002; 73(2):171-178.
Häuser W, et al. Pharmacological and non-pharmacological treatments for chronic migraine: a
systematic review and meta-analysis. Clin J Pain. 2018; 34(5):421-430.
D’Amico D, et al. Efcacy of botulinum toxin for chronic migraine: A systematic review and meta-
analysis. Neurology. 2015; 84(9):959-968.
Tassorelli C, et al. The role of the trigeminal system in headache. Curr Pain Headache Rep. 2017;
21(4):18.
Sabbagh MN, et al. Efcacy of local anesthetic and corticosteroid injections for the treatment of
chronic migraine: a systematic review. Headache. 2019; 59(6):970-981.
Ferrante T, et al. Glycerol nasal spray as a protective osmotic lm in migraine prevention: a randomized
controlled trial. J Headache Pain. 2018; 19(1):42.
Rabago D, et al. Dextrose prolotherapy for tension and migraine headache: results of a pilot study.
Headache. 2017; 57(6):917-926.
