Chronic Migraine Relapse After Stopping Prophylactics — Rapid Resolution with a Three-Step Sphenopalatine Ganglion Protocol

Clinical Summary

A 25-year-old man presented to NeuroMet with daily, disabling migraines — the worst headaches of his life. Diagnosed with migraine a decade ago and started on preventive therapy, he had stopped his medications without medical consultation. What followed was a dramatic escalation: daily migraines at maximum pain intensity. A structured three-step sphenopalatine ganglion (SPG) modulation protocol resolved his acute attack in under ten minutes, and a revised long-term plan brought his headache burden down to one manageable episode per month.

Patient Presentation

A 25-year-old male professional presented to NeuroMet Wellness Care & Diagnostics, Gurgaon, with severe, daily headaches persisting over several weeks. The pain was bilateral, throbbing, and rated 10 out of 10 on the Visual Analogue Scale (VAS).

He described associated photophobia (discomfort triggered by light) and phonophobia (sensitivity to sound), both hallmark migraine features. There was no visual disturbance, sensory change, or speech difficulty — ruling out aura.

His history revealed a diagnosis of episodic migraine without aura at around age 15. He had been started on amitriptyline (a tricyclic antidepressant commonly used as a first-line migraine prophylactic), which controlled his symptoms well. However, the patient discontinued amitriptyline on his own several years ago — without consulting his treating physician — after feeling sufficiently improved.

This is a pattern neurologists encounter frequently: a patient feels better, assumes the disease is cured, and stops preventive therapy. The migraines returned with a vengeance, escalating to daily frequency and maximal intensity, transforming an episodic condition into a near-chronic migraine pattern (defined as ≥15 headache days per month for over three months, per ICHD-3).

Clinical Examination

A thorough neurological examination was performed:

• Higher mental functions: Normal, alert, and oriented.
• Cranial nerves (I–XII): Intact bilaterally. No papilledema on fundoscopy.
• Motor system: Normal tone, power 5/5 in all limbs, no drift.
• Sensory system: No deficits.
• Cerebellar signs: Absent. Gait normal.
• Neck: Supple, no meningeal signs.
• Vitals: Within normal limits.

A completely normal neurological examination — the expected finding in primary migraine. However, the severity and daily frequency warranted workup to exclude secondary causes.

Investigations & Findings

MRI Brain (with contrast): Grossly normal brain parenchyma. No space-occupying lesion, no white matter changes, no vascular anomaly. Incidental mild mucosal thickening in the paranasal sinuses — a common, non-specific finding that does not explain migraine.

Routine blood investigations: Within normal limits.

The normal MRI and labs confirmed this as a primary headache disorder — migraine without aura — with no structural or metabolic cause.

Diagnosis

Migraine without aura — high-frequency episodic, approaching chronic transformation — precipitated by unsupervised discontinuation of prophylactic therapy.

Key differentials considered and excluded: Medication overuse headache (no frequent analgesic use), secondary headache (normal MRI/examination), new daily persistent headache (onset pattern inconsistent — clear relapse of pre-existing disorder), and sinogenic headache (mucosal thickening alone insufficient; phenotype was classic migraine).

Treatment Approach

Given the extreme pain intensity (VAS 10/10) at presentation and the need for immediate relief, a three-step sphenopalatine ganglion (SPG) modulation protocol was administered — a structured, evidence-informed approach combining pharmacological and neuromodulatory strategies:

Step 1: Intravenous Rescue Therapy (AAN Guideline-Based)

Dexamethasone 4 mg IV combined with Metoclopramide 10 mg IV was administered. This combination carries Level A evidence per AAN guidelines for acute migraine. Dexamethasone reduces neurogenic inflammation, while metoclopramide acts as both an antiemetic and a dopamine receptor antagonist with independent analgesic properties.

Step 2: Intranasal Sphenopalatine Ganglion Block

A transnasal SPG block using 2% lignocaine was performed. The sphenopalatine ganglion (SPG) is a nerve cluster deep behind the nose that acts as a relay in the parasympathetic and trigeminal pain pathways driving migraine. Delivering local anaesthetic directly to this ganglion through the nasal passage — a quick, non-invasive, office-based procedure — interrupts pain signal transmission at its source.

Step 3: Supplemental High-Flow Oxygen

Oxygen at 6 litres per minute via nasal cannula for 5 minutes was administered. While high-flow oxygen is best known as first-line therapy for cluster headache (Level A evidence), emerging evidence supports its role in migraine as well — it modulates trigeminal-autonomic reflex activity and may reduce migraine-associated vasodilation.

Result

The patient reported complete resolution of headache within approximately 8 minutes of initiating the protocol. VAS dropped from 10/10 to 0/10. No adverse effects were observed.

Long-Term Management & Follow-Up

Following the acute intervention, the patient was started on a dual prophylactic regimen:

• Flunarizine (a calcium channel blocker with established efficacy in migraine prevention) — taken at night.
• Topiramate 25 mg (a neuromodulator with Level A evidence for migraine prophylaxis) — taken in the morning.

This dual approach was chosen given the daily frequency and extreme severity, warranting aggressive prevention. Flunarizine addresses the vascular and calcium-mediated component, while topiramate stabilises cortical excitability — attacking the migraine from two different mechanisms.

The patient was strictly counselled on the importance of medication compliance and was advised never to discontinue preventive therapy without consulting his neurologist — the very mistake that triggered this relapse.

He was also enrolled in a structured headache diary via www.neurometwellness.com, enabling real-time tracking of frequency, severity, triggers, and medication use.

Current Status

At follow-up, the patient reports a dramatic improvement: headache frequency has reduced from daily episodes (VAS 10/10) to approximately one episode per month (VAS 2–3/10) — a manageable, low-impact headache that no longer disrupts daily life. He continues to maintain his headache diary and remains compliant with his prophylactic regimen.

Clinical Pearls

• Never stop migraine prophylactics without medical guidance. Patients who feel better on preventives often assume the disease is cured — it is not. Prophylactics manage the threshold; they do not cure neuronal hyperexcitability.

• The three-step SPG protocol offers rapid, office-based relief for severe migraine. IV rescue, intranasal SPG blockade, and supplemental oxygen address the attack through complementary pharmacological, neuromodulatory, and physiological mechanisms.

• Mucosal thickening on MRI is not sinusitis causing your headache. Incidental sinus findings rarely explain a migraine phenotype and should not divert the diagnosis.

• Headache diaries are a clinical tool, not optional homework. Objective tracking allows accurate prophylactic titration, early identification of medication overuse, and measurable treatment outcomes.

About the Author

This case was managed by Dr. Bhupesh Kumar Mansukhani, Neurologist & Director, NeuroMet Wellness Care & Diagnostics, Gurgaon.

For appointments: www.drbhupesh.com/book-appointment | Clinic: www.neurometwellness.com

Patient details have been de-identified and shared with appropriate consent. This case study is for educational purposes only.

References

1. Marmura MJ, Silberstein SD, Schwedt TJ. The Acute Treatment of Migraine in Adults: The American Headache Society Evidence Assessment of Migraine Pharmacotherapies. Headache. 2015;55(1):3–20.
2. Cady RK, Saper J, Dexter K, Manley HR. A double-blind, placebo-controlled study of repetitive transnasal sphenopalatine ganglion blockade with tx360 as acute treatment for chronic migraine. Headache. 2015;55(1):101–116.
3. Cohen AS, Burns B, Goadsby PJ. High-flow oxygen for treatment of cluster headache: a randomized trial. JAMA. 2009;302(22):2451–2457.
4. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1–211.
5. Silberstein SD, Holland S, Freitag F, et al. Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults. Neurology. 2012;78(17):1337–1345.
6. Robbins MS, Starling AJ, Pringsheim TM, et al. Treatment of Cluster Headache: The American Headache Society Evidence-Based Guidelines. Headache. 2016;56(7):1093–1106.