Expert Consensus Recommendations for the Performance of Peripheral Nerve Blocks for Headaches – A Narrative Review

Abstract

Objective To describe a standardized methodology for the performance of peripheral nerve blocks (PNBs) in the treatment of headache disorders. Background PNBs have long been employed in the management of headache disorders, but a wide variety of techniques are utilized in literature reports and clinical practice. Methods The American Headache Society Special Interest Section for PNBs and other Interventional Procedures convened meetings during 2010‐2011 featuring formal discussions and agreements about the procedural details for occipital and trigeminal PNBs. A subcommittee then generated a narrative review detailing the methodology. Results PNB indications may include select primary headache disorders, secondary headache disorders, and cranial neuralgias. Special procedural considerations may be necessary in certain patient populations, including pregnancy, the elderly, anesthetic allergy, prior vasovagal attacks, an open skull defect, antiplatelet/anticoagulant use, and cosmetic concerns. PNBs described include greater occipital, lesser occipital, supratrochlear, supraorbital, and auriculotemporal injections. Technical success of the PNB should result in cutaneous anesthesia. Targeted clinical outcomes depend on the indication, and include relief of an acute headache attack, terminating a headache cycle, and transitioning out of a medication‐overuse pattern. Reinjection frequency is variable, depending on the indications and agents used, and the addition of corticosteroids may be most appropriate when treating cluster headache. Conclusions These recommendations from the American Headache Society Special Interest Section for PNBs and other Interventional Procedures members for PNB methodology in headache disorder treatment are derived from the available literature and expert consensus. With the exception of cluster headache, there is a paucity of evidence, and further research may result in the revision of these recommendations to improve the outcome and safety of these interventions.

Occipital Nerve Blockage in Cervicogenic Headache: A case Report and Brief Review of Literature

“…Major occipital nerve blockage, minor occipital nerve blockage, C 2-3 nerve blockage and cervical facet joint blockage can be used in the diagnosis and treatment of cervicogenic headaches. A study which compared C 2-3 nerve blockage with major occipital nerve blockage in the diagnosis and treatment of cervicogenic headaches found the two methods to be equally effective [5,6].…”

“…Systemic complications and nerve damage may be seen associated with the use of local anesthetic. Systemic complications may include mild systemic effects, agitation, a metallic taste in the mouth, sensory deficits, cardiovascular events (tachycardia, ventricular arrhythmia and arrest) and central nervous system impairments and careless intravascular applications may result in death [2][3][4][5].…”

Primary auriculotemporal neuralgia. Case report

“…One must take care with certain populations of patients, including pregnant women, elderly, those allergic to substances used, with history of previous vasovagal episodes and in use of anticoagulants. Described peripheral anesthetic blocks involve injections in greater and lesser occipital nerves, supratrochlear, supraorbital and auriculotemporal nerves 17 . Reported complications include pain, bleeding, infection an intravascular injection 3 .…”

Botulinum neurotoxin A for chronic migraine headaches: does it work and how?

“…BoNTA, through its proposed peripheral and central mechanisms, decreases central sensitization and this raises the threshold for headache initiation [10]. Evidence in support of this concept comes from reports that single local anesthetic nerve blocks or even trigger point injections, which provide comparatively short periods of analgesia, also appear to provide long lasting relief from headache in some migraine patients [19]. It is possible that the quick onset of muscle analgesia after BoNTA injection may be as, or even more, important than a long duration of action in terms of decreasing headache frequency.…”