Occipital Nerve Blocks: When and What to Inject?

Abstract

Occipital nerve block is an effective treatment for cervicogenic headache, cluster headache, and occipital neuralgia. While a double blinded randomized placebo controlled clinical trial is lacking, multiple open label studies reported favorable results for migraine. Two other possible uses of ONB worthy of further study are use as a rescue treatment and as an adjunctive treatment for medication overuse headache. ONB may be effective for tension headache, but only under very specific circumstances. ONB is either ineffective or only effective under as yet unstudied circumstances for hemicrania continua and chronic paroxysmal hemicrania. Some practitioners use occipital nerve (ON) tenderness to palpation (TTP) or reproduction of headache pain with ON pressure (RHPONP) as selection criteria for identifying appropriate patients. While only a clinical trial can produce a definitive answer, current evidence suggests that these selection criteria are not necessary for cervicogenic headache or cluster headache. Occipital neuralgia by definition involves TTP of the ONs. Whether RHPONP or ON TTP predicts success in migraine is unclear, and may relate to whether steroids are used. A single blinded randomized controlled trial evaluating local anesthetic with steroids vs local anesthetic alone for transformed migraine reported slightly worse results with steroids, but there are several alternate explanations for this finding other than steroids being counterproductive. The technique of repetitive ONBs deserves further study.

Short-term effects of greater occipital nerve blocks in chronic migraine: A double-blind, randomised, placebo-controlled clinical trial

“…The scope of our study was to analyse the clinical outcome during the first week, concluding that GON block significantly reduces the number of moderate-to-severe headaches (and total number of headaches), at least in the short term. GON tenderness to palpation did not predict a favourable response, even though this clinical finding has been used by some practitioners as a selection criterion for the performance of GON blocks (40); this is in line with an open-label study that could not find an association between the degree of tenderness and treatment outcome in patients with CM (36). Otherwise, we were not able to find any effect of GON blocks on acute medication consumption; however, this could be explained by the exclusion of patients with medication overuse, or the low response rate of chronic pain to symptomatic treatments.…”

Headache and Neck

“…As for CeH, the cervical C1-C2 and C2-C3 facet joint blocks, as well as C2 and C3 spinal rami (including the lesser and third occipital nerves) blocks induced prolonged pain relief in more than 90% of the patients [80]. The greater occipital nerve can be easily blocked and serves as important diagnostic evidence if a temporary relief is obtained [81,82]. A greater occipital nerve block study in CeH showed significant improvement after 2 weeks [83].…”

Posttraumatic Headache in Military Personnel and Veterans of the Iraq and Afghanistan Conflicts

“…PTHAs with neuralgiform pain such as occipital or trigeminal neuralgia may benefit from treatment with an anticonvulsant such as carbamazepine, gabapentin, or lamotrigine. Occipital nerve blocks, consisting of injection of an anesthetic agent with or without corticosteroids, are used to treat a wide variety of headache syndromes [52]. A small case series of 10 patients with PTHA reported an 80% response rate with occipital nerve blockade [53,Class IV].…”