Headache LogoAHS Logo

Peripheral Nerve Blocks in Headache Treatment

Guest Editor: Matthew S Robbins, MD, FAHS

Matthew S Robbins, MD, FAHS is the chief of the neurology service at the Einstein Division of Montefiore Medical Center, the director of inpatient services for the Montefiore Headache Center, and an assistant professor of neurology at the Albert Einstein College of Medicine in the Bronx, NY. He is the current chair of the Peripheral Nerve Blocks and Other Interventional Procedures for Headache and Face Pain Section of the American Headache Society.

Peripheral nerve blocks (PNBs) have been employed in the treatment of a variety of headache disorders for decades, but only in recent years have collective clinical experiences and research been reported in the literature. Primary and secondary headache disorders, as well as cranial neuralgias, have been treated with PNBs leading to varying reports in the literature, which are mostly, but not all, observational studies. The best evidence for PNB efficacy remains for cluster headache, but there has been tremendous experience in utilizing PNBs for migraine, which is a much more common disorder.

In recent years, the Peripheral Nerve Blocks and Other Interventional Procedures section of the American Headache Society has accelerated efforts to explore practice patterns among headache practitioners and report clinical experiences in a variety of formats. Most recently, members of the section have authored a narrative review regarding a suggested methodology in the performance of PNBs, which may be quite heterogeneous in clinical practice and in literature reports, limiting comparisons across studies.

This virtual issue serves as a more broad update to one previously published, where Drs. Ashkenazi and Tobin specifically addressed occipital nerve blocks only. PNBs for headache often encompass greater occipital, lesser occipital, auriculotemporal, supratrochlear, and supraorbital nerve blocks, as well as trigger point injections.


1. Ashkenazi A, Blumenfeld A, Napchan U, Narouze S, Grosberg B, Nett R, 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.
2. Blumenfeld A, Ashkenazi A. Nerve blocks, trigger point injections and headache. Headache 2010;50:953-4.
3. Young WB, Marmura M, Ashkenazi A, Evans RW. Greater occipital nerve and other anesthetic injections for primary headache disorders. Headache 2008;48:1122-1125.

Practice Patterns and Reimbursement

1. 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 USA: Results of the American Headache Society Interventional Procedure Survey (AHS-IPS). Headache 2010;50:937-42.
2. Evans RW, Yannakakis GD. Occipital nerve blocks and managed care: a review of the reviewers. Headache 2001;41:990-1.


1. Blumenfeld A, Ashkenazi A, Napchan U, Bender SD, Klein B, Berliner R, Ailani J, Schim J, Friedman D, Charleston IV L,Young WB, Robertson CE, Dodick DW, Silberstein SD, Robbins MS. Expert Consensus Recommendations for the Performance of Peripheral Nerve Blocks for Headaches – A Narrative Review. Headache 2013, in press.
2. Tobin J, Flitman S. Occipital Nerve Blocks: When and What to Inject? Headache 2009;49:1521-1533.

Insights into Pathophysiology

1. Young W, Cook B, Malik S, Shaw J, Oshinsky M. The first 5 minutes after greater occipital nerve block. Headache 2008;48:1126-1128.
2. Cooper W. Images from Headache: Resolution of trigeminal mediated nasal edema following greater occipital nerve blockade. Headache 2008;48:278-9.
3. 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.

Primary Headache Disorders

1. Tobin J, Flitman S. Treatment of migraine with occipital nerve blocks using only corticosteroids. Headache 2011;51:155-9.
2. Baron EP, Tepper SJ, Mays M, Cherian N. Acute treatment of basilar-type migraine with greater occipital nerve blockade. Headache 2010;50:1057-9.
3. Weibelt S, Andress-Rothrock D, King W, Rothrock J. Suboccipital nerve blocks for suppression of chronic migraine: safety, efficacy, and predictors of outcome. Headache 2010;50:1041-4.
4. Tobin JA, Flitman SS. Occipital nerve blocks: effect of symptomatic medication overuse and headache type on failure rate. Headache 2009;49:1479-85.
5. Selekler M, Kutlu A, Dundar G. Orgasmic headache responsive to greater occipital nerve blockade. Headache 2009;49:130-131
6. Young WB. Cessation of hemiplegic migraine auras with greater occipital nerve blockade: a comment. Headache 2008;48:481.
7. Rozen T. Cessation of hemiplegic migraine auras with greater occipital nerve blockade. Headache 2007;47:917-9.
8. Caputi CA, Firetto V. Therapeutic blockade of greater occipital and supraorbital nerves in migraine patients. Headache 1997;37:174-9.
9. Saadah HA, Taylor FB. Sustained headache syndrome associated with tender occipital nerve zones. Headache 1987;27:201-205.

 Secondary Headache Disorders

1. Akin Takmaz S, Unal Kantekin C, Kaymak C, Basar H. Treatment of post-dural puncture headache with bilateral greater occipital nerve block. Headache. 2010;50:869-872.
2. Becker WJ. Cervicogenic headache: evidence that the neck is a pain generator. Headache 2010;50:699-705.
3. Ellis BD, Kosmorsky GS. Referred ocular pain relieved by suboccipital injection. Headache 1995;35:101-103.
4. Rothbart P. Unilateral headache with features of hemicranias continua and cervicogenic headache – A case report. Headache 1992;32:459-460.

Cranial Neuralgias

1. Evans RW. Peripheral nerve blocks and trigger point injections in headache management: trigeminal neuralgia does not respond to occipital nerve block. Headache. 2010;50:1215-1216; author reply 1216.
2. Evans RW, Pareja JA. Trochleodynia and migraine. Headache 2010;50:481-4.
3. Evans RW, Pareja JA. Expert opinion. Supraorbital neuralgia. Headache 2009;49:278-81.
4. Sjaastad O, Stolt-Nielsen A, Pareja JA, Fredriksen TA, Vincent M. Supraorbital neuralgia. On the clinical manifestations and a possible therapeutic approach. Headache 1999;39:204-12.
5. Bittar GT, Graff-Radford SB. The effects of streptomycin/lidocaine block on trigeminal neuralgia: a double blind crossover placebo controlled study. Headache 1993;33:155-60.
6. Chouret EE. The greater occipital neuralgia headache. Headache 1967;7:33-4.

Adverse Effects

1. Sprenger T, Seifert CL. Coma After Greater Occipital Nerve Blockade in a Patient With Previous Posterior Fossa Surgery. Headache 2012 Dec 8 [Epub ahead of print]
2. Lavin PJ, Workman R. Cushing syndrome induced by serial occipital nerve blocks containing corticosteroids. Headache 2001;41:902-4.

Health Care Professionals Literature

1. Robbins MS, Blumenfeld A. Peripheral nerve blocks for headaches. http://www.americanheadachesociety.org/assets/1/7/Andrew_Blumenfeld_and_Matthew_Robbins_-_Peripheral_Nerve_Blocks.pdf, accessed 1/29/13.
2. Ashkenazi A, Tobin J. Virtual Issue: Occipital Nerve Block for Headache. http://www.headachejournal.org/view/0/OccipitalNerveBlockforHeadache.html, accessed 1/29/13.

Patient Literature

1. Schwartz DP, Robbins MS. What are nerve blocks for headache? http://www.achenet.org/resources/what_are_nerve_blocks_for_headache/, accessed 1/29/13.
2. Tobin J. Nerve blocks for headaches. http://www.achenet.org/resources/nerve_blocks_for_headaches/, accessed 1/29/13.
3. Rothrock JF. Occipital nerve blocks. Headache 2010;50:917-8.

Search the Site