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Occipital Nerve Block for Headache


Avi Ashkenazi, MD*, Joshua Tobin, MD+

*The Neurologic Group of Bucks/Montgomery County, Doylestown, PA
+21st Century Neurology, Phoenix, AZ

Peripheral nerve blocks are among the most rewarding therapeutic tools in headache medicine, and have been used for this purpose for decades.1 Clinicians most frequently target the greater occipital nerve (GON), but also target various other cervical and cranial nerves to relieve both primary and secondary headache pain. Despite favorable results seen by many headache practitioners, high quality scientific data supporting their use are scarce.2,3 Most published studies on this topic are limited by a retrospective design, small sample size, heterogeneous patient groups, and lack of a control arm. Moreover, comparing studies and making generalizations is difficult because of the marked variability in the methods used in the different studies.

The American Headache Society Interventional Procedure Special Interest Section (AHS-IPS) surveyed AHS members to study their use of peripheral nerve blocks for headaches.4 We found that many headache practitioners use nerve blocks, but that the indications for using them and the methods used vary considerably among practitioners.

This issue’s collection of articles includes data on the efficacy of GON block for headaches. The articles suggest that GON block is effective for many headache disorders, and that its effect on head pain may be prompt and dramatic. However, many important questions remain: what is the optimal method to block the GON? What drugs should be used, and in what doses? Should corticosteroids be added to local anesthetics when performing the nerve block? What
clinical parameters predict a favorable outcome after a GON block? Members of the AHS- IPS convened to address these questions and to reach a consensus on recommendations for the performance of peripheral nerve blocks, based on current scientific and clinical data. The results of this effort have been recently published.5 Further studies are needed to better determine the optimal method of performing GON (and other nerve) blocks. The goals of future studies should be to identify the patients who would benefit the most from GON block, and to determine the optimal drug combination and injection technique for this procedure. This knowledge will render GOB blocks even more beneficial to our headache patients.

Review Articles and Expert Opinions:


1. Evans RW, Yannakakis GD. Occipital nerve blocks and managed care: a review of the reviewers. Headache 2001;41:990-991

2. Young WB, Marmura M, Ashkenazi A, Evans RW. Greater occipital nerve and other anesthetic injections for primary headache disorders. Headache 2008;48:1122-1125

3. Tobin J, Flitman S. Occipital nerve blocks: when and what to inject? Headache 2009;49:1521-1533

4. Ashkenazi A, Blumenfeld A, Napchan U, Narouze S, Grosberg B, Nett B, DePalma T, Rosenthal B, Tepper S, Lipton RB. Peripheral nerve blocks and trigger point injections in headache management - a systematic review and suggestions for future research. Headache 2010;50:943-952

5. Blumenfeld, A, Ashkenazi, A, Napchan, U, et al. Expert consensus recommendations for the performance of peripheral nerve blocks for headaches--a narrative review. Headache. 2013; 53:437-446

Original Research Articles and Case Reports:


1. Saadah HA, Taylor FB. Sustained headache syndrome associated with tender occipital nerve zones. Headache 1987;27:201-205

2. Rothbart P. Unilateral headache with features of hemicranias continua and cervicogenic headache – A case report. Headache 1992;32:459-460

3. Ellis BD, Kosmorsky GS. Referred ocular pain relieved by suboccipital injection. Headache 1995;35:101-103

4. Caputi CA, Firetto V. Therapeutic blockade of greater occipital and supraorbital nerves in migraine patients. Headache 1997;37:174-179

5. Lavin PJ, Workman R. Cushing syndrome induced by serial occipital nerve blocks containing corticosteroids. Headache 2001;41:902-904

6. Ashkenazi A, Young WB. The effects of greater occipital nerve block and trigger point injection on brush allodynia and pain in migraine. Headache 2005;45:350-354

7. Rozen T. Cessation of hemiplegic migraine auras with greater occipital nerve blockade. Headache 2007;47:917-919

8. Cooper W. Images from Headache: Resolution of trigeminal mediated nasal edema following greater occipital nerve blockade. Headache 2008;48:278-279

9. Young W, Cook B, Malik S, Shaw J, Oshinsky M. The first 5 minutes after greater occipital nerve block. Headache 2008;48:1126-1128

10. Selekler M, Kutlu A, Dundar G. Orgasmic headache responsive to greater occipital nerve blockade. Headache 2009;49:130-131

11. Tobin J, Flitman S. Occipital nerve blocks: effect of symptomatic medication overuse and headache type on failure rate. Headache 2009;49:1479-1485

12. AKIN TAKMAZ S, ÜNAL KANTEKİN C, KAYMAK Ç, BAŞAR H. Treatment of post-dural puncture headache with bilateral greater occipital nerve block. Headache 2010;50:869-872

13. Blumenfeld A, Ashkenazi A, Grosberg B, Napchan U, Narouze S, Nett B, DePalma T, Rosenthal B, Tepper S, Lipton RB. Patterns of use of peripheral nerve blocks and trigger point injections among headache practitioners in the US: results of the American Headache Society Interventional Procedure Survey (AHS-IPS). Headache; 2009:937-942

14. Weibelt, S, Andress-Rothrock, D, King, W, et al. Suboccipital nerve blocks for suppression of chronic migraine: safety, efficacy, and predictors of outcome. Headache. 2010; 50:1041-1044

15. Tobin, J and Flitman, S. Treatment of migraine with occipital nerve blocks using only corticosteroids. Headache. 2011; 51:155-159

16. Baron, EP, Tepper, SJ, Mays, M, et al. Acute treatment of basilar-type migraine with greater occipital nerve blockade. Headache. 2010; 50:1057-1059
 

Virtual Issue compiled online 4 June 2010
Updated on 8 October 2013

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