UUCI Health · Department of Neurology
APP Class II · Procedural Competency Series · 2026
● Procedure 07·Headache / Emergency Neurology·Moderate-risk tier
07.
Sphenopalatine Ganglion
Block.
Transnasal, bilateral.
Chadwycke R. Smith, MSN, NP, AGACNP-BC
APP Education · Department of Neurology
Approving authority: Claire Henchcliffe, MD, DPhil · Chair, Department of Neurology
APP Education · Department of Neurology
Approving authority: Claire Henchcliffe, MD, DPhil · Chair, Department of Neurology
Version 2.0 · 2026-05-11
Source-of-truth: 01_SPG_Block_Learning_Objectives.docx
Source-of-truth: 01_SPG_Block_Learning_Objectives.docx
SPG Block · UCI Neurology APP Class II
01 / 21
UUCI · APP Class II
Procedure 07 · SPG Block
One anatomic target · three primary headaches
<10min
needle-free, repeatable, deliverable in clinic or ED.
The SPG is the autonomic relay of the trigemino-autonomic reflex in cluster, migraine, and other TACs.
- Parasympathetic, sympathetic, and trigeminal pathways converge at the SPG — a single bedside target for multiple primary headaches.
- RCT signal in chronic migraine: repetitive Tx360 block reduced headache intensity vs. saline at 6 months (Cady 2015).
- Cluster headache — acute abortive and short-term prophylaxis during cluster periods (Robbins 2016).
- Acute ED migraine evidence is evolving — Schaffer 2015 saline-vs-lidocaine showed no benefit; McCarthy 2026 dose-finding bupivacaine RCT signals reassessment. Best established evidence remains chronic / cluster.
Robbins MS et al. Headache. 2016;56(2):240–58 · PMID 26615983
Cady RK et al. Headache. 2015;55(1):101–16 · PMID 25338927
McCarthy D et al. Ann Emerg Med. 2026 Jan 27 (online ahead of print) · PMID 41603837
Cady RK et al. Headache. 2015;55(1):101–16 · PMID 25338927
McCarthy D et al. Ann Emerg Med. 2026 Jan 27 (online ahead of print) · PMID 41603837
SPG Block · Why this matters
02 / 21
UUCI · APP Class II
Procedure 07 · SPG Block
01 · Cognitive
Anatomy & indications.
Identify the SPG within the pterygopalatine fossa; state accepted indications and absolute / relative contraindications.
02 · Psychomotor
Transnasal corridor.
Position the patient and advance the catheter along the nasal floor to the posterior nasopharyngeal wall — no force, pressure-not-pain.
03 · Psychomotor
Anesthetic delivery.
Verify concentration, calculate per-side and cumulative dose against ASRA LAST ceiling, instill slowly, hold the 10-minute dwell.
04 · Cognitive
Complication recognition.
Recognize epistaxis, vasovagal, and the LAST prodrome (perioral numbness, tinnitus, metallic taste). Escalate appropriately.
05 · Affective
Time-out & consent.
Lead the team-based time-out per TJC UP.01.03.01 — patient, procedure, laterality plan, anesthetic agent + concentration + volume.
06 · Affective
Documentation & escalation.
Document pre / post NRS, device, dose, dwell, complications, disposition. Escalate per pathway when relief fails or complications occur.
SPG Block · Course objectives
03 / 21
UUCI · APP Class II
Procedure 07 · SPG Block
- SPG sits in the pterygopalatine fossa, posterior to the middle turbinate.
- Largest extracranial parasympathetic ganglion — trigeminal sensory and sympathetic fibers converge here.
- Separated from the nasal cavity by 1–1.5 mm of mucosa — accessible to topical anesthetic without injection.
- Parasympathetic outflow drives lacrimation, rhinorrhea, and the cranial autonomic features of cluster and migraine.
Piagkou M et al. The pterygopalatine ganglion and its role in various pain syndromes. Pain Pract. 2012;12(5):399–412 · PMID 21956040
Robbins MS et al. Headache. 2016;56(2):240–58 · PMID 26615983
Robbins MS et al. Headache. 2016;56(2):240–58 · PMID 26615983
SPG Block · Anatomy I
05 / 21
UUCI · APP Class II
Procedure 07 · SPG Block
- Trajectory: along the nasal floor, parallel to the hard palate — not angled upward.
- Catheter tip advances past the middle turbinate to rest against the posterior nasopharyngeal wall.
- Mucosal diffusion delivers anesthetic across the lateral nasal wall to the SPG.
- Depth marker on Tx360 / SphenoCath confirms posterior placement (≈ 6 cm in most adults).
- External length should match the pre-measured tragus-to-nostril distance.
Cady RK et al. Headache. 2015;55(1):101–16 · PMID 25338927
SPG Block · Anatomy II
06 / 21
UUCI · APP Class II
Procedure 07 · SPG Block
Indications
- Chronic migraine — adjunct to oral preventives; strongest RCT evidence with repetitive Tx360 protocol.
- Cluster headache — acute abortive and short-term prophylaxis during cluster periods.
- Trigeminal autonomic cephalalgias (paroxysmal hemicrania, SUNCT) — adjunct when oral therapy partial.
- Refractory persistent headache after lumbar puncture or post-traumatic — case-series support; reasonable trial when conservative measures fail.
Cady RK et al. Headache. 2015;55(1):101–16 · PMID 25338927
Robbins MS et al. Headache. 2016;56(2):240–58 · PMID 26615983
Robbins MS et al. Headache. 2016;56(2):240–58 · PMID 26615983
Contraindications
- Absolute: active epistaxis · coagulopathy with high bleeding risk
- Absolute: severe septal deviation · recent nasal surgery · sinonasal trauma blocking the corridor
- Absolute: documented amide-LA allergy (lidocaine, bupivacaine)
- Absolute: active sinonasal infection · nasopharyngeal mass · pediatric without specific protocol
- Relative: mild septal deviation · anticoagulation amenable to brief hold · inability to tolerate supine + head extension · uncontrolled allergic rhinitis
SPG Block · Indications & contraindications
07 / 21
UUCI · APP Class II
Procedure 07 · SPG Block
- 01Indication confirmed. Accepted indication present; secondary-headache red flags screened out on focused history and exam.
- 02Allergy & contraindications. No amide-LA allergy. No active epistaxis, infection, recent nasal surgery, or sinonasal mass blocking the corridor.
- 03Consent documented. Material risks (epistaxis, dysgeusia, vasovagal, rare LAST, failed relief), alternatives, right to decline — teach-back confirmed before the procedure begins.
- 04Baseline NRS captured. Pre-block headache severity 0–10, side(s) involved, documented.
- 05Time-out called. Per TJC UP.01.03.01 — correct patient, procedure, laterality plan, anesthetic agent + concentration + volume, consent confirmed aloud.
TJC standard
UP.01.03.01
Pre-procedure verification, site identification, formal time-out — including anesthetic
agent, concentration, and volume verbalized aloud.
The Joint Commission. Universal Protocol UP.01.03.01.
TJC Hospital Accreditation Standards · 2024.
TJC Hospital Accreditation Standards · 2024.
SPG Block · Pre-procedure verification
08 / 21
UUCI · APP Class II
Key fact · dwell time
Cady · Tx360 protocol · 2015
10–15 min
indwelling dwell after intranasal lidocaine application — the evidence-based duration
before reassessment. The block is the dwell, not the injection.
01
Inject slowly
(20–30 s).
(20–30 s).
02
Hold the dwell
(10–15 min).
(10–15 min).
03
Reassess
at 15 + 30 min.
at 15 + 30 min.
Cady RK et al. Headache. 2015;55(1):101–16 · PMID 25338927
09 / 21
UUCI · APP Class II
Procedure 07 · SPG Block
Equipment checklist
- Delivery device — Tx360, SphenoCath, MiRx
- Or cotton-tipped applicator (DIY fallback)
- 3 mL syringe · Luer fit verified
- Sterile saline flush
- Gauze · emesis basin
- Non-sterile gloves · mask · eye protection
- Non-sterile drape
- NRS scale (0–10) at bedside
- BP cuff & pulse oximeter for vasovagal screen
- Lipid emulsion 20% available (LAST kit)
Anesthetic selection
- Primary: 4% lidocaine — most common in published transnasal SPG protocols
- Alternative: 0.5% bupivacaine — longer duration when prolonged effect is desired
- Small-volume topical application to the posterior middle turbinate / sphenopalatine recess mucosa
- Bilateral cumulative dose shares the ASRA LAST weight-based ceiling — recalculate per patient
- Verify concentration on the vial — not what you think it should be
Cady RK et al. Headache. 2015;55(1):101–16 · PMID 25338927 · Neal JM et al. ASRA LAST Checklist. Reg Anesth Pain Med. 2021;46(1):81–2 · PMID 33148630
SPG Block · Kit & anesthetic
10 / 21
UUCI · APP Class II
Procedure 07 · SPG Block
- Supine, head extended 20–30° — chin slightly elevated, not hyperextended.
- Goal: align the nasal floor with the posterior nasopharyngeal target plane.
- Older textbooks citing 45° are outdated — Tx360 / Cady 2015 protocol is 20–30°.
- Tilt the head ~10° toward the side being treated to pool anesthetic against the SPG mucosa.
- Position emesis basin and gauze within reach before catheter advancement.
Cady RK et al. Headache. 2015;55(1):101–16 · PMID 25338927
Patient positioning
Supine, head extended 20–30° (pillow under shoulders) — chin slightly elevated, not hyperextended
Verify before each block · positioning is critical action #8
SPG Block · Positioning
12 / 21
UUCI · APP Class II
Procedure 07 · SPG Block
01
Device prep ·
prime & verify.
- Inspect catheter for kinks · verify hub-to-tip integrity
- Draw anesthetic · verify concentration on the vial
- Attach syringe · prime with 0.5 mL to clear lumen air
- Confirm flow at the tip before nasal insertion
02
Insert along the
nasal floor.
- Parallel to the hard palate · not angled upward
- Advance steadily until depth marker reaches the naris
- ≈ 6 cm in most adults
- Tip rests at posterior nasopharyngeal wall, past the middle turbinate
03
Pressure ·
not pain.
- Pressure / fullness = correct trajectory
- Sharp pain = malposition · turbinate contact / false track
- Withdraw 1–2 cm · redirect along the floor · re-advance
- Never force a tight catheter
Cady RK et al. Headache. 2015;55(1):101–16 · PMID 25338927 · Robbins MS et al. Headache. 2016;56(2):240–58 · PMID 26615983
SPG Block · Steps 1–3
13 / 21
UUCI · APP Class II
Procedure 07 · SPG Block · Critical checkpoint
Critical safety checkpoint · before anesthetic instillation
Pressure — not pain.
Confirm before you instill.
Confirmation cues
- Patient reports pressure or fullness — not sharp pain
- Catheter depth marker aligns with the nostril rim
- External length matches pre-measured tragus-to-nostril distance
- Patient breathes through the mouth — confirms tip is below the airway plane
If position is wrong
- Withdraw 1–2 cm
- Redirect along the nasal floor
- Re-advance with the same pressure / pain feedback loop
- Never force advancement against a tight catheter
Forced advancement against pain
STOP. Withdraw.
Redirect — or abort.
Redirect — or abort.
Sharp pain or two aborted procedures in 90 days triggers focused review.
Robbins MS et al. Headache. 2016;56(2):240–58 · PMID 26615983
Robbins MS et al. Headache. 2016;56(2):240–58 · PMID 26615983
SPG Block · Position confirmation
14 / 21
UUCI · APP Class II
Procedure 07 · SPG Block
04
Slow instillation ·
20–30 seconds.
- Inject 0.5–1 mL over 20–30 s — slow rate limits posterior runoff
- Warn patient: bitter / salty taste is expected
- Lacrimation & mild rhinorrhea = parasympathetic engagement, not adverse
- Stop & reassess on cough, severe gag, or vasovagal symptoms
05
Hold the dwell ·
withdraw slowly.
- Maintain 10-minute indwelling dwell per side
- Withdraw along the same trajectory used for insertion
- Rapid withdrawal triggers sneeze reflex · aerosolizes anesthetic
- Inspect tip for integrity · gauze ready for blood-tinged discharge
06
Contralateral ·
fresh catheter.
- Bilateral default for migraine & cluster — unilateral only when strictly one-sided
- Fresh catheter on the second side
- Same anesthetic dose · cumulative against LAST ceiling
- Document side, dose, time for each block separately
Cady RK et al. Headache. 2015;55(1):101–16 · PMID 25338927
SPG Block · Steps 4–6
15 / 21
UUCI · APP Class II
Procedure 07 · SPG Block
Monitoring
- Keep patient supine for 30 minutes to maximize mucosal contact time
- Reassess NRS at 15 and 30 minutes post-block
- Monitor for vasovagal response, persistent epistaxis, new neurologic symptoms
- Screen for early LAST: perioral numbness, tinnitus, metallic taste, agitation
- Tolerance of oral intake before discharge
Discharge criteria
- Stable vital signs · ambulating without orthostasis
- Headache reduction or stable (partial response acceptable; document)
- Oral intake tolerated
- No active epistaxis · no LAST prodrome
- Return precautions reviewed · headache-clinic follow-up arranged if appropriate
Cady RK et al. Headache. 2015;55(1):101–16 · PMID 25338927
SPG Block · Post-procedure
16 / 21
UUCI · APP Class II
Procedure 07 · SPG Block
01 · Expected
Bitter / salty taste.
Posterior pharyngeal runoff. Warn the patient up front. Resolves within minutes of withdrawal.
02 · Expected
Lacrimation & rhinorrhea.
Parasympathetic engagement on the blocked side — a feature, not a bug. Confirms physiologic effect.
03 · Common
Vasovagal.
Pale, diaphoretic, near-syncope, bradycardia. Place supine, legs elevated, IV fluids if symptomatic. Pause; resume only when fully recovered.
04 · Common
Mild epistaxis.
Usually self-limited; gentle alar pressure. Persistent or recurrent bleeding requires ENT consult — most common complication overall.
05 · Uncommon
Posterior pharyngeal numbness.
Transient anesthetic effect on swallow. Hold PO until sensation returns. Reassuring; not LAST.
06 · Uncommon
Cough / gag reflex.
Anesthetic runoff to the airway. Stop instillation, sit patient up, suction if needed. Usually self-limited.
07 · Rare
Allergic reaction.
Amide-LA allergy is rare but possible. Standard anaphylaxis algorithm — epinephrine, airway, IV access.
08 · Catastrophic
LAST.
Perioral numbness, tinnitus, metallic taste → agitation → seizure → cardiovascular collapse. ASRA LAST protocol · 20% lipid emulsion.
Neal JM et al. ASRA Local Anesthetic Systemic Toxicity Checklist 2020. Reg Anesth Pain Med. 2021;46(1):81–82 · PMID 33148630
SPG Block · Complications
18 / 21
UUCI · APP Class II
Procedure 07 · SPG Block · LAST & pitfalls
ASRA LAST weight-based ceilings
| Agent | mg/kg | Adult max |
|---|---|---|
| Lidocaine (plain) | 4.5 | 300 mg |
| Lidocaine + epi | 7 | 500 mg |
| Bupivacaine | 2 | 175 mg |
A bilateral SPG block — 0.5 mL × 4% lidocaine × 2 sides — delivers 40 mg total, well below the ceiling. Bilateral cumulative dose shares the ceiling; recalculate every time.
LAST response · 20% lipid emulsion · 1.5 mL/kg bolus · 0.25 mL/kg/min infusion (max 12 mL/kg)
Four pitfalls we see
- Wrong trajectory: angling the catheter upward toward the cribriform instead of along the floor. Parallel to the hard palate, not pointing at the eye.
- Rushing the dwell: <10 min contact time, then declaring the block ineffective. The block is the dwell.
- Bilateral dose stacking: calculating each side independently against the LAST ceiling. Cumulative bilateral dose shares the same maximum.
- Skipping the time-out / baseline NRS: no documented baseline = no demonstrable response; no time-out = no defense.
SPG Block · LAST & pitfalls
19 / 21
UUCI · APP Class II
Procedure 07 · SPG Block · Competency & sources
FPPE / OPPE — SPG block
| Stage | Scope |
|---|---|
| FPPE | First 5 independent cases after Board approval · concurrent per-case review within 14 days · aggregate at 5 · target close in 6 mo |
| OPPE | Every 6 mo · 10% sample (min 2, max 10) · 100% review on complication flag |
| Lapse | < 3 SPG blocks over 24 mo → simulation + 1 proctored case to reinstate |
Tracked OPPE indicators
- Bilateral completion (or documented rationale) 100%
- Epistaxis rate ≤ 10% rolling 6-mo
- Documentation completeness 100%
- Post-procedure observation compliance ≥ 95%
- Severe complication — 100% per-case review
Moderate-risk tier · simulation recommended
- 01Robbins MS, Robertson CE, Kaplan E, et al. The sphenopalatine ganglion: anatomy, pathophysiology, and therapeutic targeting in headache. Headache. 2016;56(2):240–58. PMID 26615983.
- 02Cady RK, Saper J, Dexter K, Manley HR. A double-blind, placebo-controlled study of repetitive transnasal SPG blockade with Tx360 as acute treatment for chronic migraine. Headache. 2015;55(1):101–16. PMID 25338927.
- 03Schaffer JT, Hunter BR, Ball KM, Weaver CS. Noninvasive sphenopalatine ganglion block for acute headache in the ED: a randomized placebo-controlled trial. Ann Emerg Med. 2015;65(5):503–10. PMID 25577713.
- 04Maizels M, Scott B, Cohen W, Chen W. Intranasal lidocaine for treatment of migraine: a randomized, double-blind, controlled trial. JAMA. 1996;276(4):319–21. PMID 8656545.
- 05Piagkou M, 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(5):399–412. PMID 21956040.
- 06Neal JM, Neal EJ, Weinberg GL. ASRA Local Anesthetic Systemic Toxicity Checklist: 2020 Version. Reg Anesth Pain Med. 2021;46(1):81–82. PMID 33148630.
- 07McCarthy D, Borrayes L, Hopper E, et al. A randomized, dose-finding study of sphenopalatine ganglion block with bupivacaine for emergency department patients with headache. Ann Emerg Med. 2026 Jan 27 (online ahead of print). PMID 41603837.
- 08The Joint Commission. Universal Protocol UP.01.03.01. TJC Hospital Accreditation Standards; 2024.
- 08aThe Joint Commission. Universal Protocol UP.01.01.01 — preprocedure verification; use a standardized list (H&P, signed consent, nursing & preanesthesia assessment, labeled imaging, required equipment/devices). National Patient Safety Goals (HAP); effective January 2025.
- 08bThe Joint Commission. NPSG.01.01.01 EP 1 — use at least two patient identifiers (room number is not an identifier) before any treatment or procedure. National Patient Safety Goals (HAP); effective January 2025.
- 08cThe Joint Commission. NPSG.07.01.01 EP 1 — implement CDC and/or WHO hand-hygiene categories IA, IB, IC. National Patient Safety Goals (HAP); effective January 2025.
- 08dThe Joint Commission. Universal Protocol UP.01.02.01 EP 5 — written alternative process for site marking when anatomy precludes a mark (mucosal surfaces, perineum, premature infants, teeth, minimal-access procedures treating a lateralized internal organ). Documented per hospital policy. National Patient Safety Goals (HAP); effective January 2025.
- 08eThe Joint Commission. NPSG.03.04.01 — label all medications, medication containers, and solutions on and off the sterile field (name, strength, amount, diluent, expiration). EP 4 requires two-individual verification when preparer ≠ administrator. National Patient Safety Goals (HAP); effective January 2025.
- 09The Joint Commission. HR.01.06.01 — competence verified before care; MS.08.01.01 / MS.08.01.03 — FPPE / OPPE. 2024.
- 10CDC. Guideline for Hand Hygiene in Health-Care Settings. MMWR. 2002;51(RR-16):1–44.
- 11UCI APP Class 2 Training Plan Process. Department of Neurology, University of California, Irvine. April 2026.
SPG Block · FPPE / OPPE & references
20 / 21