Disappointing Results from a Trial of Intranasal Bupivacaine for Headache

Published in Ann Emerg Med 2015 Jan 7

Authors: Schaffer JT et al.

Intranasal lidocaine has shown promise as a migraine treatment, but a trial of bupivacaine for unselected headaches disappoints.

Prior research has shown intranasal lidocaine to be an effective treatment for migraine (NEJM JW Emerg Med Aug 16 1996). Now, investigators report results of a randomized, controlled, manufacturer-sponsored trial of intranasal bupivacaine for unselected headaches in 93 emergency department patients.

Patients with any acute headache of frontal or global location received 0.5% bupivacaine or saline placebo administered intranasally with a novel device that injects topical medicine directly onto the mucosa overlying the sphenopalatine ganglion. The main outcome, headache relief 15 minutes after treatment, did not differ between groups. However, at 24 hours, more patients in the bupivacaine group than the placebo group were headache free (72% vs. 48%).

Comment
Knowing the onset of action and half-life of bupivacaine, why the investigators chose to assess outcome at 15 minutes is unclear, as it was too short a time period. Also, this study included various headache types, while the prior, successful trial focused on migraine. Further study is required, and we should not give up on this treatment yet. The ideal approach is probably a mixture of lidocaine and bupivacaine dripped into the naris with the patient supine with the head rotated toward the side of the headache. The proprietary device is probably not necessary.