Efficacy of greater occipital nerve block for pain relief in patients with postdural puncture headache

Abstract

Background: This study aimed at assessing the therapeutic effectiveness of greater occipital nerve block (GONB) against postdural puncture headache (PDPH). Methods: Studies investigating analgesic effects of GONB against PDPH in adults were retrieved from the MEDLINE, EMBASE, Google scholar, and Cochrane central databases from their inception dates to May, 2021. Pain score at postprocedural 24 hours was the primary endpoint, while secondary endpoints were pain score at postprocedural 1 hour and 12 hours as well as the risk of intervention failure. Results: Of the 7 studies (randomized controlled trials [RCTs], n = 4; non-RCTs, n = 3) that recruited 275 patients, 2 investigated female patients undergoing cesarean section and the other 5 were conducted in both obstetric and nonobstetric settings. Pooled results showed a lower mean pain score at 24 hours (i.e., primary outcome) (mean difference [MD] = –2.66, 95%: CI: –3.98 to –1.33, P < .001; I 2 = 97%, 6 studies), 1 hour (MD = –4.23, 95% confidence interval [CI]: –5.08 to –3.37, P < .00001; I 2 = 86%, 5 studies), and 6 hours (MD = –2.78, 95% CI: –4.99 to –0.57, P = .01; I 2 = 98%, 4 studies) in patients with GONB compared to those without. Trial sequential analysis supported the robustness of evidence at postprocedural 24 hours. The use of GONB also decreased the risk of intervention failure (relative ratio [RR] = 0.4, 95% CI: 0.19 to 0.82, P = .01; I 2 = 96%, 6 studies, 277 patients). Conclusion: Our results suggested a therapeutic effect of greater occipital nerve block against postdural puncture headache up to postprocedural 24 hours. Further large-scale studies are warranted to evaluate its therapeutic benefit beyond the acute stage.

Headaches in Pregnancy and Postpartum

“…There are recent studies, however, that suggest sphenopalatine ganglion block may also be an effective, less invasive successful treatment modality (161,162,167). Additionally, occipital nerve blocks have been used successfully in postdural headaches in patients with symptoms refractory to other treatments (168,169). Both sphenopalatine ganglion block and occipital nerve blocks are supported by case reports, but there is currently insufficient evidence to recommend either sphenopalatine ganglion or occipital nerve blocks as the primary treatment of obstetric PDP headache (170).…”

Consensus Practice Guidelines on Postdural Puncture Headache From a Multisociety, International Working Group

“…Seventh, fibrin glue should be reserved for management of PDPH refractory to EBP or when autologous blood injection is contraindicated (evidence grade: I; level of certainty: low). Important supporting references were Russell et al, Melchart et al, Sluder, Giaccari et al, and Chang et al…”

“…Fourth, regular multimodal analgesia, including acetaminophen and nonsteroidal antiinflammatory drugs, should be offered to all patients with PDPH unless contraindicated 41 8 Melchart et al, 43 Sluder, 44 Giaccari et al, 45 and Chang et al 46 Question 7: Is Imaging Required in PDPH Management?…”

Etiology, management, and sequela of postdural puncture headache

“…A 2021 meta-analysis examining GON blocks for the treatment of PDPH found that it reduces pain scores for 24 h and may obviate the need for EBP. However, they were only able to find four RCTs to include in their analysis, and there was a high heterogenicity of the data [68]. At this time, it is not possible to definitively state that GON blocks are effective at managing PDPH without further trials and more data.…”