Occipital Nerve Blocks: Effect of Symptomatic Medication

Objective.— To explore the effect of symptomatic medication overuse (SMO) and headache type on occipital nerve block (ONB) efficacy.
Methods.— We conducted a chart review of all of the ONBs performed in our clinic over a 2-year period.
Results.— Of 108 ONBs with follow-up data, ONB failed in 22% of injections overall. Of the other 78%, the mean decrease in head pain was 83%, and the benefit lasted a mean of 6.6 weeks. Failure rate without SMO was 16% overall, and with SMO was 44% overall ( P  < .000). In those who did respond, overall magnitude and duration of response did not differ between those with and those without SMO. Without SMO, ONB failure rate was 0% for postconcussive syndrome, 14% for occipital neuralgia, 11% for non-intractable migraine, and 39% for intractable migraine. With SMO, failure rate increased by 24% ( P  = .14) in occipital neuralgia, by 36% ( P  = .08) for all migraine, and by 52% ( P  = .04) for non-intractable migraine.
Conclusions.— SMO tripled the risk of ONB failure, possibly because medication overuse headache does not respond to ONB. SMO increased ONB failure rate more in migraineurs than in those with occipital neuralgia, possibly because migraineurs are particularly susceptible to medication overuse headache. This effect was much more pronounced in non-intractable migraineurs than in intractable migraineurs.     

Cushing Syndrome Induced by Serial Occipital Nerve Blocks Containing Corticosteroids

A patient with chronic daily headaches developed overt signs of Cushing syndrome during treatment with serial occipital nerve block injections. Investigation demonstrated an exogenous source of corticosteroids as the cause of the Cushing syndrome in this patient, thus, implicating the corticosteroid component of the occipital nerve blocks. To our knowledge, this is the first report of Cushing syndrome caused by occipital nerve blockade. Caution is warranted in employing even usual therapeutic doses of synthetic corticosteroids, particularly in long-acting or depot preparations.     

Occipital Nerve Blocks: When and What to Inject?

Introduction.— Occipital nerve block (ONB) is a promising treatment for headaches. Its indications, selection criteria, and best techniques are not clear, however. Objective.— To summarize in narrative format what is known about ONBs and what needs to be learned. Methods.— MD Consult and Google Scholar were searched using the terms occipital, suboccipital, block, and injection to identify relevant articles that were reviewed. This process was repeated for all additional pertinent articles identified from these articles, and so on, until no additional articles were identified. Results.— A total of 21 articles were identified. Conclusions.— Occipital nerve block is an effective treatment for cervicogenic headache, cluster headache, and occipital neuralgia. While a double blinded randomized placebo controlled clinical trial is lacking, multiple open label studies reported favorable results for migraine. Two other possible uses of ONB worthy of further study are use as a rescue treatment and as an adjunctive treatment for medication overuse headache. ONB may be effective for tension headache, but only under very specific circumstances. ONB is either ineffective or only effective under as yet unstudied circumstances for hemicrania continua and chronic paroxysmal hemicrania. Some practitioners use occipital nerve (ON) tenderness to palpation (TTP) or reproduction of headache pain with ON pressure (RHPONP) as selection criteria for identifying appropriate patients. While only a clinical trial can produce a definitive answer, current evidence suggests that these selection criteria are not necessary for cervicogenic headache or cluster headache. Occipital neuralgia by definition involves TTP of the ONs. Whether RHPONP or ON TTP predicts success in migraine is unclear, and may relate to whether steroids are used. A single blinded randomized controlled trial evaluating local anesthetic with steroids vs local anesthetic alone for transformed migraine reported slightly worse results with steroids, but there are several alternate explanations for this finding other than steroids being counterproductive. The technique of repetitive ONBs deserves further study.     

Nerve Stimulator-Guided Occipital Nerve Blockade for Postdural Puncture Headache

Postdural puncture headache (PDPH) is one of the most common complications of spinal anesthesia, where adequate hydration with bed rest in the horizontal position is the initial recommendation. Epidural blood patch is to date the most effective treatment, but it is an invasive procedure that may result in serious complications. The aim of the current study was to conduct a prospective, randomized, single-blinded comparison between bilateral occipital blockade and conventional expectant therapy in adults suffering from PDPH. A primary hypothesis was that occipital blockade would result in better pain management and quicker return to normal activity. Fifty adult patients diagnosed with PDPH were randomly divided into two equal groups of 25 each. All patients in the block group received greater and lesser occipital nerve blocks, whereas the control group received adequate hydration, complete bed rest, and analgesics. Forty-seven patients entered into the final analysis as three patients withdrew from study. Complete pain relief was achieved in 68.4% of block patients after 1 to 2 blocks, with 31.6% ultimately receiving up to 4 blocks. Visual analog scales were significantly lower in the block group ( P  < 0.01), and the block group consumed significantly less analgesics in the follow-up period ( P  < 0.05) compared with control group. Block patients had significantly shorter hospital stays and sick leave periods ( P  < 0.001). The studied method is superior to expectant conservative therapy in the treatment of patients suffering from PDPH.     

Occipital Nerve Release in Patients With Whiplash Trauma and Occipital Neuralgia

The results of 18 greater occipital nerve release operations in 13 patients were analyzed. All patients had deep aching pain in the occipital area due to a whiplash trauma, and in all cases the pain was relieved temporarily by local anesthesia of the occipital nerve. The time from accident to operation was 6 to 96 months. The results of 13 (72.2%) operations were reported as good or excellent, although complete pain relief was not attained in any patient. It is concluded that neurolysis of the greater occipital nerve after whiplash injury can give meaningful pain relief in selected patients.     

Transient Facial Nerve Palsy After Occipital Nerve Block: A Case Report

Occipital nerve blocks are commonly performed to treat a variety of headache syndromes and are generally believed to be safe and well tolerated. We report the case of an otherwise healthy 24‐year‐old woman with left side‐locked occipital, parietal, and temporal pain who was diagnosed with probable occipital neuralgia. She developed complete left facial nerve palsy within minutes of blockade of the left greater and lesser occipital nerves with a solution of bupivicaine and triamcinolone. Magnetic resonance imaging of the brain with gadolinium contrast showed no abnormalities, and symptoms had completely resolved 4‐5 hours later. Unintended spread of the anesthetic solution along tissue planes seems the most likely explanation for this adverse event. An aberrant course of the facial nerve or connections between the facial and occipital nerves also might have played a role, along with the patient's prone position and the use of a relatively large injection volume of a potent anesthetic. Clinicians should be aware that temporary facial nerve palsy is a possible complication of occipital nerve block.     

Occipital Nerve Stimulation for Migraine: A Systematic Review

Patients who suffer from migraines often report impaired quality of life. Occipital nerve stimulation (ONS) is a novel treatment modality for migraines, although few systematic reviews have evaluated whether this therapy is efficacious. The objective of this study was to evaluate the clinical efficacy and safety of ONS for treating migraine through a literature review. We performed a literature search to identify studies that investigated ONS for migraine treatment. Evidence levels of these studies were assessed by recommendations set by the University of Oxford Centre for Evidence‐Based Medicine. Five randomized controlled trials, 4 retrospective studies, and one prospective study met the inclusion criteria. Results from the retrospective studies and case series indicated that ONS significantly reduced the pain intensity and the number of days with headache in patients with migraine. However, the evidence of ONS efficacy established by randomized controlled trials was limited. Improvement in the migraine disability assessment (MIDAS) score was more dramatic than improvement in the SF‐36 score at follow‐up. The mean complication incidence of ONS was 66% for the reviewed studies. Future clinical studies should optimize and standardize the ONS intervention process and identify the relationship among the surgical process, efficacy, and complications resulting from the procedure.     

Sustained Headache Syndrome Associated with Tender Occipital Nerve Zones

SYNOPSIS
A sustained headache syndrome can develop from headaches of diverse etiologies. Over seven years,112 patients with such a syndrome received 188 sets of injections in the occipital nerve regions andtwo-thirds had prolonged relief. In such headaches, interrupting the pain cycle with occipital injectionscontaining 1% lidocaine plus betamethasone may be a useful adjunct to other preventive and abortivemedical therapies.     

Botulinum Toxin Occipital Nerve Block for the Treatment of Severe Occipital Neuralgia: A Case Series

▪ Abstract:   Persistent occipital neuralgia can produce severe headaches that are difficult to control by conservative or surgical approaches. We retrospectively describe a series of six patients with severe occipital neuralgia who received conservative and interventional therapies, including oral antidepressants, membrane stabilizers, opioids, and traditional occipital nerve blocks without significant relief. This group then underwent occipital nerve blocks using the botulinum toxin type A (BoNT-A) BOTOX® Type A (Allergan, Inc., Irvine, CA, U.S.A.) 50 U for each block (100 U if bilateral). Significant decreases in pain Visual Analog Scale (VAS) scores and improvement in Pain Disability Index (PDI) were observed at four weeks follow-up in five out of six patients following BoNT-A occipital nerve block. The mean VAS score changed from 8 ± 1.8 (median score of 8.5) to 2 ± 2.7 (median score of 1), while PDI improved from 51.5 ± 17.6 (median 56) to 19.5 ± 21 (median 17.5) and the duration of the pain relief increased to an average of 16.3 ± 3.2 weeks (median 16) from an average of 1.9 ± 0.5 weeks (median 2) compared to diagnostic 0.5% bupivacaine block. Following block resolution, the average pain scores and PDI returned to similar levels as before BoNT-A block. In conclusion, BoNT-A occipital nerve blocks provided a much longer duration of analgesia than diagnostic local anesthetics. The functional capacity improvement measured by PDI was profound enough in the majority of the patients to allow patients to resume their regular daily activities for a period of time. ▪     

Blocking the Greater Occipital Nerve: Utility in Headache Management

Occipital nerve block has been part of headache medicine for more than half a century, with injection techniques and solutions varying greatly. Most studies have been case series and many show benefit for patients with migraine, cluster headache, and postconcussive headache. A double-blind, controlled trial of cluster headache has demonstrated that injectable steroids with local anesthetics benefit cluster headache patients. A double-blind, controlled trial of nerve blocks in occipital neuralgia, which may have actually been chronic migraine, was positive.     

Occipital Neuromodulation: Ultrasound Guidance for Peripheral Nerve Stimulator Implantation

We report a case of chronic left‐sided occipital neuralgia in a 21‐year old female patient. The patient in question suffered from chronic greater occipital neuralgia for a duration of many years, which had been refractory to other conservative medical management strategies. Blockade of the greater occipital nerve with local anesthetic was consistently useful in attenuating the patient's pain, though the effects were always short lived. Consequently, a successful trial of greater occipital nerve stimulation was undertaken. Compared with spinal cord stimulation, peripheral nerve stimulation devices are often more difficult to precisely place given limited ability to visualize soft tissues with traditional fluoroscopic guidance. Additionally, there are anatomic subtleties relevant to the greater occipital nerve that potentially complicate stimulator lead placement, both from the standpoint of optimal neuromodulation efficacy and maximum safety. Ultrasound technology is a maturing imaging modality that allows soft tissue visualization and is consequently useful in addressing each of these aforementioned concerns. The specific use of high‐frequency ultrasound guidance for this procedure simplified the initial device placement and allowed proper visualization of soft tissue structures, which facilitates precise device deployment. Additionally, the ability to identify relevant vascular structures may further increase the safety of stimulator lead placement. The potential advantages of ultrasound‐augmented procedural techniques, specifically as they pertain to occipital stimulator lead placement, are discussed with particular emphasis on potentially decreasing intraoperative and postoperative complications while optimizing stimulation efficacy.     

Nerve Blocks in Pediatric and Adolescent Headache Disorders

Purpose of Review

Peripheral nerve blocks of the scalp, mainly greater occipital nerve blocks, have received a renewed interest amongst pediatric providers as they offer an alternate option to provide both acute and chronic relief from the suffering of children with difficult to treat headaches. This narrative review will provide an in-depth discussion of the published pediatric-specific studies exploring the utility of nerve blocks for pediatric headache disorders.

Recent Findings

A total of seven pediatric publications have been reported to date and reveal excellent therapeutic effectiveness of bilateral greater occipital nerve blocks on primary chronic headaches and post-traumatic headaches. Lidocaine is the preferred anesthetic choice and the value-added of concomitant steroids remains to be elucidated. It is important to ensure complete paresthesia of the blocked nerves to maximize effectiveness.

Summary

The available studies suggest that peripheral nerve blocks of the scalp are an excellent tool that frontline clinicians can add to their armamentarium in treating pediatric headaches.