Outcomes of Greater Occipital Nerve Injections in Pediatric Patients With Chronic Primary Headache Disorders

Abstract

Background Chronic migraine is common in pediatrics and generally disabling. In adults, infiltration of the area around the greater occipital nerve can provide short to medium term benefit in some patients. This study reports the efficacy of greater occipital nerve infiltrations in pediatric patients with chronic primary headache disorders. Methods Retrospective chart review of patients <18 years with a chronic primary headache disorder undergoing a first-time injection. Infiltrations were unilateral and consisted of a mixture of methylprednisolone acetate, adjusted for weight, and lidocaine 2%. Results Forty-six patients were treated. Thirty-five (76%) had chronic migraine, nine (20%) New Daily Persistent Headache (NDPH), and two (4%) a chronic trigeminal autonomic cephalalgia. Medication overuse was present in 26%. Ages ranged from 7–17 years. Follow-up data were available for 40 (87%). Overall, 53% (21/40) benefitted, 52% (11/21) significantly. Benefit onset ranged from 0–14 days, mean 4.7(SD 4.3), with mean benefit duration of 5.4(SD 4.9) weeks. In chronic migraine, 62% (18/29) benefitted, 56% (10/18) significantly. In NDPH, 33% (3/9) benefitted; 33% (n=1) significantly. Neither child with a chronic trigeminal autonomic cephalalgia benefitted. In logistic regression modeling, medication overuse, age, sex, and sensory change in the distribution of the infiltrated nerve did not predict outcome. There were no serious side effects. Conclusions Greater occipital nerve injections benefitted 53% of pediatric patients with chronic primary headache disorders. Efficacy appeared higher in chronic migraine than NDPH. Given the benign side effect profile, a greater occipital nerve infiltration prior to more aggressive approaches seems appropriate.

Medication Overuse in Children and Adolescents

“…In an open-label study these injections appear to be beneficial in 53% of children and adolescents with chronic primary headache disorders 15 . Importantly, the odds of benefit are not reduced in the setting of medication overuse (OR 1.1, 95% CI 0.3–4.5) 15 .…”

“…In an open-label study these injections appear to be beneficial in 53% of children and adolescents with chronic primary headache disorders 15 . Importantly, the odds of benefit are not reduced in the setting of medication overuse (OR 1.1, 95% CI 0.3–4.5) 15 . Similarly in an open-label adult study of greater occipital nerve injections for chronic primary headache disorders the presence of medication overuse did not predict poor treatment response 29 .…”

Trigeminal Autonomic Cephalalgias in Children and Adolescents: Cluster Headache and Related Conditions

“…Greater occipital nerve injection with lidocaine (2%) and depo-methylprednisolone can foreshorten the bout without any other treatment and is very well tolerated even in the young 23 . Some would use an oral corticosteroid taper, as is done in adults, 14 we find this less attractive in children.…”

Targeting pericranial nerve branches to treat migraine: Current approaches and perspectives

“…The major studies are summarized in Table 1 ( [51][52][53][54][55][56][57][58][59][60][61][62]. Unfortunately, there are very few controlled trials and no standardized methods were used for the selection of migraine patients (some had fixed unilateral headache, others not), the timing of infiltrations (ictal or interictal), the technique of infiltrations or blocks (unilateral or bilateral, association with blocks of other pericranial nerves or trigger point injections, one or more interventions), the compounds used for the blocks (local anesthetics alone or combined with different types and dosages of steroids) and particularly the evaluation of outcomes (number of headache-free days, variable percentage reduction of headache days or attacks, non-uniformly standardized pain indices).…”