Severe headache is a hallmark of aneurysmal subarachnoid hemorrhage (SAH), plaguing up to 90% of patients during hospitalization. Opioids remain the mainstay of acute therapy, despite their significant limitations through side effects and high potential for tolerance and addiction. Furthermore, a significant proportion of patients report inadequate pain control with conventional medication regimens. Pterygopalatine fossa (PPF) nerve blocks are used for various headache disorders and anesthesia for midface procedures, but have not been used for SAH-related headache. We report our initial experience using a PPF block as novel treatment strategy for refractory headaches in SAH.

Retrospective review of patients with SAH who received a PPF block as adjunct means of pain control during hospitalization for SAH. Patient demographic and clinical characteristics, and hourly pain scale scores (0-10) for the 24 hr period prior and after PPF block were extracted from the medical record.

Six patients received a uni- or bilateral PPF block during the study period. Mean age was 56 ± 10 years, 2 were male. Average pain scores for the 24-hour period prior versus after block placement was 5.5 ± 1.4 vs 3.4 ± 2.2 (p=0.0395). Pain relief was sustained for an average of 20 hours after block placement (range 5-48 hours). All patients tolerated the PPF well without major side effects.

We report a novel strategy for pain control after SAH utilizing a PPF block. PPF blocks, shown effective in midface procedures and headache disorders, target nervous structure involved in headache generation in SAH. In our case series, all patients who received a PPF block for refractory headaches experienced significant reduction of pain scores post block. PPF blocks may present a safe, effective and potentially opiate-sparing treatment strategy for headache after SAH. Larger studies evaluating efficacy, safety and opiate-sparing effect of PPF block after SAH are planned.