Expert Opinion: Greater Occipital Nerve and Other Anesthetic Injections for Primary Headache Disorders

Jefferson Headache Center, Thomas Jefferson University, Philadelphia, PA, USA.
Headache The Journal of Head and Face Pain (Impact Factor: 2.71). 08/2008; 48(7):1122-5. DOI: 10.1111/j.1526-4610.2008.01192.x
Source: PubMed


(Headache 2008;48:1122-1125)

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    • "One is the proximal injection technique: anesthetic is injected into the muscle at the point of greater occipital nerve (GON) exit. As a result, the paraspinal muscles near the injection site are also infiltrated with anesthetic, coming to paraspinal muscle injection that may well be a trigger point injection [4]. The other technique (traditional technique) is administered more distally: GONB is performed just medial to the occipital artery, which is palpated at 2.5-3 cm lateral to the occipital protuberance [5-7]. "
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    ABSTRACT: Greater occipital nerve block is used in the treatment of headaches and neuralgia in the occipital area. We evaluated the efficacy of ultrasonic doppler flowmeter-guided occipital nerve block in patients experiencing headache in the occipital region in a randomized, prospective, placebo-controlled study. Twenty-six patients, aged 18 to 70, with headache in the occipital region, were included in the study. Patients received a greater occipital nerve block performed either under ultrasonic doppler flowmeter guidance using 1% lidocaine or the traditional method. Sensory examination findings in the occipital region were evaluated. The complete block rate of greater occipital nerve blockade in the doppler group was significantly higher than in the control group respectively (76.9% vs. 30.8%, P < 0.05). Only one patient in the control group had a complication (minimal bleeding). Ultrasonic doppler flowmeter-guided occipital nerve block may be a useful method for patients suffering headache in the occipital region.
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    ABSTRACT: Cluster headache (CH) is a primary headache syndrome that is classified with the trigeminal autonomic cephalalgias. CH treatment involves three steps: acute attack management, transitional therapy, and preventive therapy. Greater occipital nerve block has been shown to be an effective alternative bridge therapy to oral steroids in CH. Botulinum toxin type A has recently been studied as a new preventive treatment for patients with chronic CH, with limited success.
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    ABSTRACT: Occipital nerve block (ONB) is a promising treatment for headaches. Its indications, selection criteria, and best techniques are not clear, however. To summarize in narrative format what is known about ONBs and what needs to be learned. MD Consult and Google Scholar were searched using the terms occipital, suboccipital, block, and injection to identify relevant articles that were reviewed. This process was repeated for all additional pertinent articles identified from these articles, and so on, until no additional articles were identified. A total of 21 articles were identified. 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.
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