100 Migraine Drugs, A to Z: bupivacaine

Bupivacaine (Marcaine, Sensorcaine) is a numbing agent (local anesthetic) similar to lidocaine (Xylocaine), but with a longer duration of effect. Bupivacaine effect lasts 4 to 8 hours, while lidocaine, only 2 hours. However, lidocaine begins to work in 2 to 5 minutes, while bupivacaine takes 5 to 10 minutes.

We use bupivacaine to treat migraines in two ways. One is in combination with lidocaine to perform nerve blocks. Nerve blocks can be very effective in stopping a stubborn migraine that does not respond to medications such as triptans, NSAIDs, intravenous magnesium, ketorolac, and other. We also give nerve blocks to pregnant women who fail to respond to intravenous magnesium and before using systemic drugs, that is drugs taken by mouth or by injection and that are distributed throughout the body, including the fetus.

The nerve blocks are done with small needles, although during a migraine attack even a small needle can be painful. However, relief from the numbing effect of lidocaine comes within minutes, while bupivacaine in the mixture provides longer lasting relief. Some headache specialists give regular nerve blocks every 3 months in place of onabotulinumtoxinA (Botox) injections. Nerve blocks are not as effective as Botox, but we do give nerve blocks when the effect of Botox wears off sooner than 3 months. Ideally, we try to give Botox earlier, but many insurance companies will not allow Botox injections more often than every 3 months.

We also use bupivacaine by itself for sphenopalatine ganglion (SPG) blocks . These blocks are not painful since they are done without a needle. Bupivacaine is delivered to the ganglion which is located behind the nasal cavity and underneath the brain through a thin plastic catheter (we use Tx360 device). The SPG block can be also effective for the treatment of an acute cluster headache.