PONOS CLINIC · SPECIALIST PAIN CARE
SPG and cluster headache
A pathway for selected cases.
In resistant headaches, assessment of trigeminal-autonomic pathways may help define appropriate care options.
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Cluster Headache and Refractory Headaches: When Pain Becomes Complex
Cluster headache represents one of the most intense and disabling forms of craniofacial pain.
In chronic, high-frequency, or medication-refractory cases, the pain assumes characteristics of complexity that require dedicated specialist evaluation.
Alongside cluster headache, there are other refractory headaches and forms of complex craniofacial pain in which trigeminal autonomic mechanisms play a significant role.
The Role of the Sphenopalatine Ganglion in Trigeminal Autonomic Cephalalgias
The sphenopalatine ganglion (SPG) is a key structure in trigeminal autonomic circuits, particularly involved in cluster headache and headaches with marked autonomic features.
Its involvement is suggested by:
- lacrimation, rhinorrhoea, nasal congestion
- periocular redness or oedema
- paroxysmal pain pattern
- consistent laterality of attacks
In these presentations, the SPG is not the “sole cause” of pain, but a peripheral component of trigeminal-autonomic pathways.
When to Consider an SPG Pathway
Treatment of the sphenopalatine ganglion is considered only in selected patients, in the presence of:
- chronic or refractory cluster headache
- insufficient response or intolerance to medications
- refractory trigeminal autonomic cephalalgias
- craniofacial pain with clear autonomic component
It is not a first-line therapy.
It is not indicated for all headaches.
Patient selection is the critical step.
Specialist Pathway: Method and Gradual Approach
PONOS Clinic’s approach to refractory headaches and the SPG follows a structured pathway, which may include:
- Comprehensive specialist clinical evaluation
- Critical review of therapeutic history
- Assessment of headache pattern
- Possible transmucosal test for diagnostic purposes
- Assessment of whether CT is needed for anatomical planning
- Consideration of interventional techniques only when indicated
Each phase has a precise rationale.
There are no shortcuts.
Diagnostic Tests and Their Significance
The transmucosal test of the sphenopalatine ganglion can provide useful indications regarding the possible role of the SPG in headache, but:
- it may provide temporary relief, but the response alone does not establish the source of the pain
- it does not guarantee the success of subsequent treatments
- it must be interpreted within the overall clinical context
A positive response guides, it does not decide.
Interventional Techniques: When and Why
In properly selected patients, consideration may be given to pulsed radiofrequency of the sphenopalatine ganglion, with the aim of modulating neural activity.
The technique is evaluated:
- only after proper assessment
- only after adequate anatomical study
- only in the presence of appropriateness criteria
Not all patients with cluster headache are candidates for this treatment.
Treatment of the sphenopalatine ganglion is not a therapeutic shortcut.
Expected Benefits and Limitations
In selected cases, treatment of the SPG may lead to:
- reduction in attack intensity
- reduction in frequency
- improvement in quality of life
The response is variable and individual.
There are no guaranteed results.
For a comprehensive overview of the diagnostic and therapeutic pathway, visit the page
Turin Headache Centre – Resistant migraines and craniofacial pain
Clinical experience
Radiofrequency of the sphenopalatine ganglion has been performed by Dr Evangelos Panagiotakos within an individual assessment and selection pathway.
Pathway Map – SPG
The specialist pathway for sphenopalatine ganglion treatment.
The Transmucosal Test: Value and Limitations
The transmucosal test of the sphenopalatine ganglion is a simple diagnostic procedure that can provide useful indications regarding the possible involvement of the ganglion in the pain presentation.
It is important to clarify that:
- the block may have a temporary therapeutic effect
- a positive response does not guarantee the success of more advanced treatments
- a negative response does not automatically rule out SPG involvement
The test must be interpreted within the overall clinical context, not in isolation.
→ dedicated page: “Transmucosal Test of the Sphenopalatine Ganglion”
Pulsed Radiofrequency of the Sphenopalatine Ganglion
When indicated, pulsed radiofrequency of the sphenopalatine ganglion represents an advanced interventional technique, aimed at modulating neural activity, not destroying the structure.
It is performed:
- in a suitable clinical setting, with sterile precautions and monitoring
- under instrumental (fluoroscopic) guidance
- with parameters selected on a case-by-case basis
The objective is to reduce pain intensity and frequency, while preserving the anatomical integrity of the ganglion.
→ dedicated page: “Pulsed Radiofrequency of the Sphenopalatine Ganglion”
Potential benefits and limitations
In properly selected patients, benefits may include:
- reduction in pain intensity
- possible reduction in attack frequency
- possible improvement in quality of life
The goal is not only to treat “the ganglion,” but to understand the pain and the patient’s needs.
References
EAN, 2023 — Cluster headache guidelines · Ho et al., 2017 — SPG systematic review
Frequently asked questions
Does a positive block guarantee later treatment success?
No. The response is interpreted alongside the diagnosis and other clinical findings.
Does every patient need a procedure?
No. Each step is considered only when it answers a clinical question or offers an appropriate balance of potential benefit and risk.