Effectiveness and safety profile of greater occipital nerve blockade in cluster headache: a systematic review

Abstract

BackgroundGreater occipital nerve (GON) blockade is a short-term preventive therapy for cluster headache (CH). We conducted a systematic review to evaluate the effectiveness and safety of GON blockade in patients with CH.MethodsOn 23 October 2020, we searched MEDLINE, Embase, Embase Classic, PsycINFO, CINAHL, CENTRAL and Web of Science databases from their inception date. Studies included participants with a CH diagnosis who received corticosteroid and local anaesthetic suboccipital region injections. Outcomes were change in the frequency/severity/duration of attacks; proportion of participants responding to treatment, time to attack freedom from an attack, change in attack bout length and/or the presence of adverse effects after GON blockade. Risk of bias was assessed with the Cochrane Risk of Bias V.2.0 (RoB2)/Risk of Bias in Non-randomized Studies - of Interventions (ROBINS- I) tools and a specific tool for case reports/series.ResultsTwo RCTs, eight prospective and eight retrospective studies, and four case reports were included in the narrative synthesis. Every effectiveness study found a significant response in one or more of frequency/severity/duration of individual attacks or proportion of patients responding to treatment (47.8%–100.0%). There were five instances of potentially irreversible adverse effects. A higher injectate volume and use of concurrent prophylaxis may be associated with an increased likelihood of response. Methylprednisolone may have the best safety profile of available corticosteroids.DiscussionGON blockade is safe and effective for CH prevention. Higher injectate volumes may improve likelihood of response, and the likelihood of serious adverse events may be reduced by using methylprednisolone.PROSPERO registration numberCRD42020208435.

Cluster Headache, SUNCT, and SUNA

“…14 Greater occipital nerve injections have used a variety of steroids, and all seem to be effective. 54 Several immediate side effects of steroids are notable including insomnia, agitation (including mania in patients with bipolar disorder), and hyperglycemia (especially in those with diabetes). Delayed side effects include gastrointestinal ulcers, adrenal suppression, and avascular necrosis of the hip, and for these reasons, short courses of oral steroids (21 days or less) are recommended.…”

“…The American and European guidelines have differed on the effectiveness of oral steroids, but a recent successful clinical trial has given more guidance by using a higher dose than typically used: prednisone 100 mg daily for 5 days, with a taper schedule decreasing by 20 mg every 3 days until off 14 . Greater occipital nerve injections have used a variety of steroids, and all seem to be effective 54 . Several immediate side effects of steroids are notable including insomnia, agitation (including mania in patients with bipolar disorder), and hyperglycemia (especially in those with diabetes).…”

Medication-overuse headache: a narrative review

“…Its use has not been tested in a placebo-controlled trial in MOH patients. A recent meta-analysis on its use in cluster headache exemplifies the heterogeneity of the techniques utilised, the combination or not of corticosteroids and local anesthetics and the laterality of injections [45]. Our practice is to use 2 mL of lidocaine 2% along with 2 mL of methylprednisolone (80 mg).…”