Occipital and Trigeminal Nerve Blocks for Migraine

Abstract

To block or not to block, that is the question. CLINICAL HISTORIESCase 1.-This is a 53-year-old male seen for consultation due to headaches since high school, which have been almost daily for the past 20 years. He describes a throbbing pain behind the left eye, with an intensity of 5-9/10 and posterior cervical pressure, occasionally associated with nausea and vomiting, but no light or sound sensitivity. He takes rizatriptan 10 mg daily, and the headache is gone in about 1 hour. Every couple of weeks, the headache recurs and he takes another dose of rizatriptan. He takes hydrocodone 1-2 tablets every couple of weeks. Alcohol triggers his headaches. Sumatriptan injections and baclofen did not help. He has tried topiramate, amitriptyline, divalproex sodium, gabapentin, and propranolol for headache prevention, without help. He also tried onabotulinumtoxinA once, without help. Chiropractic treatment did not help. He has not tried acupuncture. Magnetic resonance imaging of the brain with and without contrast, done 3 months previously, was negative. He has a past medical history of hyperlipidemia, treated with a statin. Neurological examination was normal. There was bilateral greater occipital nerve (GON) tenderness. Bilateral greater occipital nerve block (GONB) was performed by injection of 3 mL of 1% lidocaine 2 cm lateral and 2 cm inferior to the inion on each side. For headache prevention, he was started on zonisamide 100 mg daily for 2 weeks and then 200 mg daily. He was informed on the risk of medication overuse headache with frequent use of rizatriptan. He was seen in follow-up 2 months later. During the 2 weeks after the occipital nerve blocks (ONBs), he had one headache that was quickly relieved by rizatriptan. For the following 14 days, he experienced headaches once every other day, and thereafter his daily headache pattern resumed, with prompt relief by rizatriptan.Case 2.-This is a 45-year-old woman with a 15-year history of migraine without aura occurring about 2-3 times per month. She takes eletriptan 40 mg tablets, with relief of the headache in 2 hours. She presents with a 2-day history of a typical right-sided throbbing headache of 9/10 intensity, associated with nausea, vomiting, as well as light and sound sensitivity. Her symptoms did not respond to 2 doses of eletriptan and promethazine suppository. A right GONB was performed by injection of 3 mL of 1% lidocaine 2 cm lateral and 2 cm inferior to the inion, with relief of the headache within 10 minutes. Subsequently, she has had 2 similar episodes that were quickly relieved by ONBs.Case 3.-This is a 58-year-old male seen in consultation with headaches since high school, which have been daily for the past month. Prior to that, he had approximately 4 headache days per week for many years. He describes a bilateral retro-orbital and temporal pain with nuchal-occipital throbbing and pres-

Influence of Levobupivacaine Regional Scalp Block on Hemodynamic Stability, Intra- and Postoperative Opioid Consumption in Supratentorial Craniotomies: A Randomized Controlled Trial

“…Scalp infiltration or regional scalp block (SB) has been proposed to be part of this type of multimodal approach to prevent hemodynamic responses to noxious stimulation during craniotomy and to prevent postoperative pain [5][6][7] . It has been used for chronic subdural hematomas drainage 8 , treatment of chronic neuralgias of the great occipital nerve 9,10 , and awake craniotomies 11 successfully. SB necessitates the subcutaneous infiltration of local anesthetic agents at several points over the scalp surface, which is highly vascularized.…”

Ultrasound-Guided Combined Greater Occipital Nerve Block at the C2 Level with Trapezius Trigger Point Injection and Supraorbital-Supratrochlear Nerve Block: More Effective on Allodynia and Disability in Chronic Migraine

“…PTNB, TPI, and GONB are often used because they are safe, well-tolerated, and effective in treating migraines, allodynia, and photophobia. [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 ] In general, 48 to 100% of adult migraineurs receive full or partial relief from migraine prevention that lasts a few days to several months. [ 6 ] The combination of GONB and TPI has been found to reduce allodynia in previous studies, with 85% improvement between 5 and 20 min and 1 week after therapy.…”

“…[ 5 ] Trigger point injections (TPIs), supraorbital and supratrochlear nerve blocks (SONB, STNB), and greater occipital nerve block (GONB), which are all effective migraine treatments, can be used when medical therapy fails. [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 ] Myofascial discomfort can cause or contribute to headache syndromes by generating trigger points, which are areas of concentrated allodynia. The trapezius muscle, the most typical headache trigger point location, can induce pain in the temporal, jaw, occiput, and upper neck regions.…”

Sports and Headaches

“…Occipital neuralgia may improve with local anesthetic nerve blocks, which are effective alone or combined with an injectable corticosteroid if patients do not respond adequately to local anesthetics alone (eg, 3 mL of 1% lidocaine or 2.5 mL of 1% lidocaine and 3 mg of betamethasone) . Occipital nerve blocks can be effective for posttraumatic occipital neuralgia in adolescent and adult athletes and for prevention of migraine . Botulinum toxin injection may also be effective …”