Nerve blocks in the treatment of headache

Auriculotemporal neuralgia overlapped with chronic orofacial myofascial pain: A case report of a challenging diagnosis

AIM

Auriculotemporal neuralgia (AN) is a rare condition characterized by severe, stabbing, unilateral pain inadequately described in the literature. Often coexisting with other conditions sharing the same innervation, and this overlap complicates clinical interpretation, leading to diagnostic errors and inappropriate therapeutic choices. The absence of AN in headache and facial pain diagnostic criteria hampers access to crucial information for diagnostic reasoning.Thus, we aimed to report a case of AN overlapped with another orofacial pain condition.

METHOD AND RESULT

We present a case of overlap between chronic orofacial myofascial pain (MP) and AN, where conservative MP treatment did not provide the patient with complete pain relief. After diagnosing AN, a single anesthetic block induced complete pain remission over a 2-year follow-up.

CONCLUSION

These findings support reintroducing AN into diagnostic criteria, aiding clinicians in diagnostic reasoning, and preventing unnecessary interventions.

Use of corticosteroids for adult chronic pain interventions: sympathetic and peripheral nerve blocks, trigger point injections - guidelines from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, the International Pain and Spine Intervention Society, and the North American Spine Society

BACKGROUND

There is potential for adverse events from corticosteroid injections, including increase in blood glucose, decrease in bone mineral density and suppression of the hypothalamic-pituitary axis. Published studies note that doses lower than those commonly injected provide similar benefit.

METHODS

Development of the practice guideline was approved by the Board of Directors of American Society of Regional Anesthesia and Pain Medicine with several other societies agreeing to participate. The scope of guidelines was agreed on to include safety of the injection technique (landmark-guided, ultrasound or radiology-aided injections); effect of the addition of the corticosteroid on the efficacy of the injectate (local anesthetic or saline); and adverse events related to the injection. Based on preliminary discussions, it was decided to structure the topics into three separate guidelines as follows: (1) sympathetic, peripheral nerve blocks and trigger point injections; (2) joints; and (3) neuraxial, facet, sacroiliac joints and related topics (vaccine and anticoagulants). Experts were assigned topics to perform a comprehensive review of the literature and to draft statements and recommendations, which were refined and voted for consensus (≥75% agreement) using a modified Delphi process. The United States Preventive Services Task Force grading of evidence and strength of recommendation was followed.

RESULTS

This guideline deals with the use and safety of corticosteroid injections for sympathetic, peripheral nerve blocks and trigger point injections for adult chronic pain conditions. All the statements and recommendations were approved by all participants after four rounds of discussion. The Practice Guidelines Committees and Board of Directors of the participating societies also approved all the statements and recommendations. The safety of some procedures, including stellate blocks, lower extremity peripheral nerve blocks and some sites of trigger point injections, is improved by imaging guidance. The addition of non-particulate corticosteroid to the local anesthetic is beneficial in cluster headaches but not in other types of headaches. Corticosteroid may provide additional benefit in transverse abdominal plane blocks and ilioinguinal/iliohypogastric nerve blocks in postherniorrhaphy pain but there is no evidence for pudendal nerve blocks. There is minimal benefit for the use of corticosteroids in trigger point injections.

CONCLUSIONS

In this practice guideline, we provided recommendations on the use of corticosteroids in sympathetic blocks, peripheral nerve blocks, and trigger point injections to assist clinicians in making informed decisions.

Rectus Sheath Blocks for Umbilical Hernia Reductions in the Emergency Department: A Case Series

Introduction

Rectus sheath blocks have been used for decades in the operating room for analgesia following umbilical surgical procedures. We present the first reported case series of a rectus sheath block used in the emergency department (ED) for the reduction of an umbilical hernia.

Case Series

Four patients presented to the ED for painful, non-reducible umbilical hernias. An ultrasound-guided bilateral rectus sheath block was used in all four patients with complete pain relief and an easy hernia reduction.

Conclusion

Rectus sheath blocks are an excellent addition to a multimodal analgesic regimen in periumbilical pain and painful procedures. This block is easy to perform and implement for pain control in umbilical hernias in an ED setting.

The effect of simultaneous administration of occipital nerve block and cervical myofascial trigger point injection (MTrPI) on headache parameters in chronic migraine patients

BACKGROUND AND AIM

Peripheral myofascial mechanisms have been identified as contributors to migraine pathophysiology. The specific comorbid relationship between migraine and cervical trigger points may exacerbate the occurrence and severity of migraine attacks. Trigger point injections (TPIs) are frequently employed to address headaches and alleviate migraine symptoms. The current study explores the impact of concurrent myofascial trigger point injection (MTrPI) and occipital nerve block (greater occipital nerve block [GONB] + lesser occipital nerve block [LONB]) on the severity of headaches and the number of migraine attacks in individuals with chronic migraine (CM) and cervical myofascial trigger points (MTrPs), with a comparison of occipital nerve block alone (GONB + LONB). During trigger point examination and injection, trapezius, levator scapulae, splenius capitis, temporalis, and sternocleidomastoid muscles were targeted. We planned the treatment based on whether they were in the muscle groups we determined, rather than the number of trigger points.

MATERIALS AND METHOD

This study enrolled 62 individuals experiencing CM with bilateral headache and cervical MTrP who sought care at the Algology Unit within the Departments of Neurology and Physical Therapy and Rehabilitation at Siirt Training and Research Hospital between 2020 and 2022. The CM cohort was stratified into two groups: group 1 received trigger point injections (TrPI), while group 2 underwent concurrent bilateral occipital nerve block (GONB + LONB) and TrPI. Both groups underwent three treatment sessions with bupivacaine 0.5% (1 ml = 5 mg) in weeks 1, 2, and 4. Visual analog scale (VAS) was used to measure the patients' pain intensity. The evaluation included the assessment of the monthly migraine frequency and visual analog scale (VAS) p score for pain before treatment (BT) and after treatment (AT), conducted at baseline and during follow-up visits. Analysis of the data was conducted utilizing IBM SPSS Statistics for Windows version 28.0 software.

RESULTS

Among patients diagnosed with CM and MTrPs, 32 individuals (51.6%) underwent GONB and LONB, while 30 patients (48.4%) received simultaneous GONB, LONB, and cervical MTrPI. Within the entire sample, 51 participants (82.3%) were female, and 11 (17.7%) were male, with a mean age of 32.81 ± 10.75 years. With an average age of 32.81 ± 10.75 years, there was no statistically significant variance between the two groups (p = 0.516). Of the total cohort, 45 individuals (72.6%) reported experiencing headaches persisting for 12 months or longer. Among CM patients, 80% had active trigger points, while 20% had latent trigger points. No statistically significant difference was observed between the groups concerning TrPs (p = 0.158), and the distribution of TrPs was homogenous across the two groups. In group 1, the median (min-max) monthly frequency of migraines reduced from 18.5 days (range: 15.0 to 25.0 days) before treatment to 12.0 days (range: 7.0 to 17.0 days) after treatment (p = 0.000). In group 2, the median monthly frequency of migraines reduced from 16.5 days (range: 15.0 to 22.0 days) before treatment to 4.0 days (range: 2.0 to 8.0 days) after treatment (p = 0.000). The median (min-max) VAS score in group 1 was 8.0 (range: 5.0 to 9.0) before treatment, 4.0 (range: 2.0 to 6.0) at week 1, and 5.0 (range: 4.0 to 8.0) at week 4 (p = 0.000). In group 2, the median VAS score was 7.0 (range: 5.0 to 9.0) before treatment, 0.0 (range: 0.0 to 0.3) at week 1, and 2.0 (range: 0.0 to 0.3) at week 4 (p = 0.000). There were significant distinctions between the groups in terms of both the monthly count of migraine days and the severity of headaches (p = 0.000).

CONCLUSION

The combination of repeated MTrPIs and ONB proves more effective than ONB alone in managing patients with CM and cervical MTrP. In patients with CM, performing TrPs examination and adding treatments for this may contribute to the treatment. In cases where patients endure prolonged episodes of headache associated with chronic migraine, the inclusion of trigger point injections alongside peripheral nerve blocks may offer enhanced therapeutic benefits.

Nerve Blocks for Craniotomy

PURPOSE OF REVIEW

Postcraniotomy headache (PCH) is a common adverse event and can lead to various complications and decreased quality of life.

RECENT FINDINGS

To reduce postcraniotomy pain and associated complications, a multimodal pain therapy including analgesics, analgesic adjuncts, and regional anesthesia is essential. The use of opioids should be minimized to facilitate prompt postoperative neurosurgical assessment. Here, we provide an update on the latest evidence regarding the role of scalp nerve blocks in the pain management of patients undergoing craniotomy procedure. Nerve blocks are effective in alleviating postoperative pain after craniotomy. Scalp blocks contribute to lower pain levels and less opioid consumption in the first 48 h following surgery. Moreover, there is a significant decrease in patients suffering from PONV among patients who receive scalp block.

Comparison of the Efficacy of Two Different Local Anesthesia Techniques for Mesotherapy in Temporal Region Alopecia

Introduction Mesotherapy is a wide range of minimally invasive injections. In mesotherapy, a mixture of various tonics is injected into the skin. These include plant extracts, various medications, vitamins, enzymes, hormones, growth factors, and other factors that will help treat alopecia. Most commonly, a mixture of platelet-rich plasma (PRP) and vitamins is used. In mesotherapy treatment for hair regrowth in the temporal region, zygomaticotemporal nerve blocks, supratrochlear nerve blocks, and supraorbital nerve blocks are given. The zygomaticotemporal nerve, supraorbital nerve, and supratrochlear nerve are the branches of the trigeminal nerve. They provide sensation on the lateral side of the forehead, which is the temple region.  Methods A sample size of 100 people was taken for the study who were undergoing mesotherapy in the bilateral temporal region for alopecia. Each group had 50 subjects: group I was given supratrochlear, supraorbital, and zygomaticotemporal nerve blocks as local anesthesia techniques, and group II was given supratrochlear and supraorbital nerve blocks. PRP was injected using an insulin syringe. Pain was assessed using a visual analog scale (VAS). Results During the procedure, a mean VAS of 1 and 3 was observed in groups I and II, respectively, during the procedure (p-value 0.023). A mean VAS of 3 and 5 was observed in groups I and II, respectively, after three hours (p-value 0.000). This shows a significant difference in the pain experienced by the subjects between the groups.  Conclusion This study proves that the zygomaticotemporal nerve, used along with supratrochlear and supraorbital nerve blocks, is better at producing analgesia and reducing pain.

Comparison of the Efficacy Between Regional Nerve Block and Ring Block as Local Anesthetic Techniques for Platelet-Rich Plasma Treatment

Introduction Platelet-rich plasma (PRP), a solution of concentrated platelets, has been widely used to promote wound repair and tissue regeneration. In the treatment of pattern hair loss, platelets in PRP secrete an abundance of growth factors, including platelet-derived growth factor (PDGF), fibroblast growth factor(FGF), and many more, which stimulate and increase signaling molecules and accelerate cell proliferation. In the PRP treatment for hair regrowth, the supratrochlear nerve (STN) block and supraorbital nerve (SON) block are given to anesthetize the scalp up to the vertex except for the temporal region. The ring block is the common local anesthetic technique used by infiltrating local anesthetic agents around the target area. The primary objectives were to compare the pain and anesthetic success rates produced by regional nerve blocks and ring blocks. Materials and methods A sample size of 100 patients undergoing PRP treatment for hair regrowth were taken as the subjects for the study. Patients were allotted into two groups by randomization. Group 1 was given regional nerve blocks as the anesthetic technique used for local anesthesia, and group 2 was given ring blocks. In the study group, STN and SON blocks as the regional nerve blocks were given 2% lignocaine with 1:80000 adrenaline to anesthetize the area, and the PRP was injected from the anterior hairline up to the vertex of the scalp, not involving the occipital and temporal regions. In the control group, a ring block was given for the same procedure. Participants from both groups were assessed for the pain and analgesia caused by ring block and regional nerve blocks using the visual analog scale (VAS). Results A mean rank of 30.28 was observed for the regional nerve block technique, and a mean rank of 70.72 was observed for the ring block technique. A p-value of 0.00 that is <0.05 was observed, which shows there is a significant difference in the pain and the analgesia experienced by the subjects between the two groups, during and three hours after the procedure. Conclusion PRP is one of the most commonly used treatments for hair regrowth. The ring block is the common local anesthetic technique used for producing anesthesia, while regional nerve blocks are more effective in producing local anesthesia. This study proves that STN and SON blocks are better anesthetic techniques than the ring block technique for PRP treatment in hair growth.

Managing and Preventing Migraine in the Emergency Department: A Review

Migraine is a leading cause of disability worldwide, and acute migraine attacks are a common reason for patients to seek care in the emergency department (ED). There have been recent advancements in the care of patients with migraine, specifically emerging evidence for nerve blocks and new pharmacological classes of medications like gepants and ditans. This article serves as a comprehensive review of migraine in the ED, including diagnosis and management of acute complications of migraine (eg, status migrainosus, migrainous infarct, persistent aura without infarction, and aura-triggered seizure) and use of evidence-based migraine-specific treatments in the ED. It highlights the role of migraine preventive medications and provides a framework for emergency physicians to prescribe them to eligible patients. Finally, it evaluates the evidence for nerve blocks in the treatment of migraine and introduces the possible role of gepants and ditans in the care of patients with migraine in the ED.

Nonpharmacologic Treatments for Chronic and Episodic Migraine: A Systematic Review and Meta-Analysis

BACKGROUND

Minimally invasive techniques for treatment-resistant migraine have been developed on recent insights into the peripheral pathogenesis of migraines. Although there is a growing body of evidence supporting these techniques, no study has yet compared the effects of these treatments on headache frequency, severity, duration, and cost.

METHODS

PubMed, Embase, and Cochrane Library databases were searched to identify randomized placebo-controlled trials that compared radiofrequency ablation, botulinum toxin type A (BT-A), nerve block, neurostimulation, or migraine surgery to placebo for preventive treatment. Data on changes from baseline to follow-up in headache frequency, severity, duration, and quality of life were analyzed.

RESULTS

A total of 30 randomized controlled trials and 2680 patients were included. Compared with placebo, there was a significant decrease in headache frequency in patients with nerve block ( P = 0.04) and surgery ( P < 0.001). Headache severity decreased in all treatments. Duration of headaches was significantly reduced in the BT-A ( P < 0.001) and surgery cohorts ( P = 0.01). Quality of life improved significantly in patients with BT-A, nerve stimulator, and migraine surgery. Migraine surgery had the longest lasting effects (11.5 months) compared with nerve ablation (6 months), BT-A (3.2 months), and nerve block (11.9 days).

CONCLUSIONS

Migraine surgery is a cost-effective, long-term treatment to reduce headache frequency, severity, and duration without significant risk of complication. BT-A reduces headache severity and duration, but it is short-lasting and associated with greater adverse events and lifetime cost. Although efficacious, radiofrequency ablation and implanted nerve stimulators have high risks of adverse events and explantation, whereas benefits of nerve blocks are short in duration.

Literature Review: Pericranial Nerve Blocks for Chronic Migraines

Purpose of Review

Headaches, especially migraines, are one of the most pervasive neurological disorders affecting up to 15.9% of the population. Current methods of migraine treatment include lifestyle changes, pharmacologic, and minimally invasive techniques such as peripheral nerve stimulation (PNS) and pericranial nerve blocks (PNB).

Recent Findings

PNBs are used to treat and prevent migraines and involves injection of local anesthetics with or without corticosteroids. PNBs include the greater occipital, supraorbital, supratrochlear, lesser occipital, auriculotemporal, sphenopalantine ganglion, and cervical root nerve blocks. Of the PNBs, the most extensively studied is the greater occipital nerve block (GONB) which has been shown to be an efficacious treatment for migraines, trigeminal neuralgia, hemi-crania continua, and post-lumbar puncture, post-concussive, cluster, and cervicogenic headaches but not medication overuse and chronic tension type headaches.

Summary

In this review, we aim to summarize the recent literature on PNBs and their efficacy in the treatment of migraines including a brief discussion of peripheral nerve stimulation.

Peripheral Nerve Blocks: A Tool for Inpatient Pediatric Status Migrainosus

BACKGROUND

To assess the efficacy and safety of peripheral nerve blocks in the inpatient settings for pediatric patients presenting with status migrainosus.

METHODS

An analysis of a retrospective cohort of patients aged 13 to 18 years, admitted for status migrainosus from 2017 to 2022, was performed. Among the 1805 patients who presented with status migrainosus, 265 required hospital admission. A total of 177 patients failed the first- and second-line intravenous therapy and were treated with either peripheral nerve block (PNB) or dihydroergotamine (DHE) intravenous infusions. The primary outcome of the study was pain score level reduction by 50%, and the secondary outcome was duration of hospital stay. Visual analog scale score was used for pain assessment.

RESULTS

Among the 177 patients, 100 patients were treated with DHE and 77 were treated with PNB. Target pain control was achieved in 59 of 100 patients receiving DHE and 38 of 77 patients receiving PNB. The average hospital stay of patients who responded to PNB was significantly lower compared with that of patients receiving DHE (3.6 days vs 4.9 days). Among the 41 patients who were refractory to DHE, 30 patients received PNB, of which 12 responded to nerve blocks. The most common side effects for PNBs were pain at injection site in 39% of patients and nausea/vomiting for DHE in 50% of patients.

CONCLUSIONS

PNB can be safely administered in the hospital setting to pediatric patients with status migrainosus. PNB treatment helped achieve target pain control with minimal side effects and reduced the hospital stay duration.

Head and Neck Cancer-Related Pain

Pain is a common and most debilitating symptom of head and neck cancers (HNC). The prevalence of pain in HNC is nearly 70%. There are no universally accepted classification or diagnostic criteria for HNC-related pain, and currently, HNC-related pain is classified based on the underlying pathophysiological mechanism, the location of the tumor, and the protagonist of pain. The clinical presentation of HNC-related pain varies and can be similar to primary pain disorders. The management of HNC-related pain primarily consists of pharmacotherapy. However, in some cases, interventions may be needed. This article will present a case study and review the epidemiology, diagnostic criteria and classification, clinical features, pathophysiology, and HNC-related pain management.

Greater occipital nerve block in patients with primary headache and early term results

Purpose: Peripheral nerve blocks have long been used in headache treatment and greater occipital nerve (GON) blocks are the most frequently preferred peripheral nerve blocks in patients with headaches in the past years. In this study, the efficacy of GON blocks in patients with primary headache disorders was evaluated. Materials and Methods: This retrospective cohort study was undertaken in April 2021 and April 2022. One hundred twenty-one patients with primary headache disorders were included. Changes in the duration and frequency of headache attacks, pain severity, and type of oral medication before and after the injection treatment during the first and third months of follow-up were evaluated. Results: The number of headache attacks decreased from 13 to 5 and the visual analogue scale(VAS) score decreased from 9 to 5 at the end of the third month in the migraine group. Similarly, the number of headache attacks decreased from 17 to 7 and the VAS score decreased from 8 to 4 in tension-type headache (TTH) group. Improvements in all parameters were found to be statistically significant in both groups. Conclusion: GON block is a low-cost, rapid and minimally invasive treatment, and our data support that this method can be an effective treatment option in patients with migraine and TTH who are resistant to oral medication by reducing the number, frequency and severity of headache attacks. In conclusion, GON blockade should be considered by clinicians as a primary treatment option in patients with migraine and TTH resistant to oral medication.

Current practice for primary headache disorders and perspectives on peripheral nerve blocks among emergency physicians in Canada: A national survey

OBJECTIVE

This national postal survey aimed to examine Canadian emergency physicians' practice patterns with respect to drug treatment and perspectives on peripheral nerve blocks.

BACKGROUND

The treatment of primary headache disorders in the emergency department is variable.

METHODS

We surveyed 500 emergency physicians listed in the Canadian Medical Directory according to a modified Dillman's method: an initial invitation was followed by up to four reminders to nonresponders. Physicians were asked questions regarding their frequency of medication administration and perspectives toward peripheral nerve blocks.

RESULTS

Of 500 mailed surveys, 468 were delivered and 179 physicians responded (response rate = 38.2%). The majority of physicians were men (92/144, 63.9%); 80.6% (116/144) had been in practice for greater than or equal to 10 years with 50.7% (75/148) in a community or district general teaching hospital. Commonly used pharmacotherapies for primary headaches were intravenous dopamine receptor antagonists (69%), co-administration of ketorolac and a dopamine receptor antagonist (54.2%), intravenous fluid boluses (54%), nonsteroidal anti-inflammatory drugs (NSAIDs) alone (53.5%), and acetaminophen (51.4%). Only 80 of 144 physicians (55.6%) reported previous experience with peripheral nerve blocks (95% confidence interval [CI] = 48%-65%). The majority (68/80, 85.0%) agreed peripheral nerve blocks are safe and 55.1% (43/78) agreed they are effective. The vast majority (118/140, 84.3%) would consider peripheral nerve blocks as a first-line treatment option given sufficient evidence from a future trial (95% CI = 78%-90%).

CONCLUSION

NSAIDs alone, as well as dopamine receptor antagonists with or without ketorolac are commonly used for primary headache in Canadian emergency departments. A large proportion of physicians have never used a peripheral nerve block in their practice; among those who have experience with peripheral nerve blocks, the majority find them safe and effective. The majority of respondents would consider peripheral nerve blocks as a first-line treatment option given sufficient evidence from a future trial.

Effectiveness of Peripheral Nerve Blocks for the Treatment of Primary Headache Disorders: A Systematic Review and Meta-Analysis

STUDY OBJECTIVE

Primary headache disorders are prevalent and account for 2% of all emergency department visits. Current treatment options are effective; however, time to pain relief is suboptimal. Alternatives such as peripheral nerve blocks have shown promising results. The objective of this systematic review is to examine the effectiveness of peripheral nerve blocks for timely pain relief.

METHODS

We searched Ovid MEDLINE, EMBASE, Web of Science Core Collection, and the Cochrane Central Register of Controlled Trials and included randomized controlled trials comparing peripheral nerve blocks to placebo or active therapy. The primary outcome was pain within 120 minutes. Secondary outcomes were pain after 120 minutes, adverse events, need for rescue medications, and relapse of headache. Two reviewers screened and extracted data independently; mean differences (MDs) were calculated, and results were pooled using a random-effects model.

RESULTS

Eleven studies met our eligibility criteria (n=860), of which 9 were included in the meta-analysis. Pain scores were significantly lower in patients treated with peripheral nerve blocks than with placebo at 15 minutes (MD: -1.17; 95% confidence interval: -1.82 to -0.51) and 30 minutes (MD: -0.99; 95% confidence interval: -1.66 to -0.32), and no serious adverse events were reported. Pain scores for peripheral nerve blocks versus active therapy and secondary outcomes were not pooled due to clinical heterogeneity.

CONCLUSION

Our review shows peripheral nerve blocks are effective as a rapid treatment option when compared to placebo; however, we were unable to assess effectiveness against standard treatment. Emergency physicians should consider peripheral nerve blocks as an adjunct therapy for patients with primary headache disorders.

Approach to Pediatric Intractable Migraine

PURPOSE OF REVIEW

Intractable migraine in children and adolescents is a significant cause of disability and decreased quality of life (QoL) in this population. Challenges include lack of unifying definition for intractable migraine, and limited data on best-practice management in this age group, with most current treatment pathways extrapolated from adult studies or expert consensus.

RECENT FINDINGS

A comprehensive approach in the evaluation and management of intractable migraine in this age group encompasses excluding secondary causes of headache; making an accurate diagnosis; identifying and appropriately managing modifiable risk factors; and initiating appropriate pharmacologic therapy to reduce disability, improve health-related quality of life, reduce risk of progression, and develop adaptive pain coping strategies. Several strategies for management of pediatric intractable migraine including use of acute medications, bridge therapy in outpatient setting, emerging therapies for preventive therapy, and a stepwise combination therapy for management of pediatric intractable migraine in emergency and inpatient setting are presented based on available clinical data, safety/tolerability, availability, cost-effectiveness, and expert consensus. This descriptive review of the available literature focuses on approach to therapy for acute intractable migraine in a pediatric population including outpatient, emergency department (ED), and inpatient management.

Clinical Characteristics and Therapeutic Results in a Series of 68 Patients with Occipital Neuralgia

OBJECTIVE

Cranial pain is a condition that has a negative impact on human lives, and occipital neuralgia is among its causes. This study aims to evaluate the clinical characteristics and therapeutic results of a series of patients with occipital neuralgia.

DESIGN

Prospective registry (observational study).

SETTINGS

Headache outpatient clinic in a tertiary hospital.

SUBJECTS

Sixty-eight cases.

METHODS

Demographic and nosological characteristics have been analyzed, as well as treatment response of occipital neuralgia. All patients were recruited between January 2008 and January 2018, and the diagnosis of occipital neuralgia was made according to the International Headache Society (International Classification of Headache Disorders) criteria being utilized at the time of diagnosis.

RESULTS

Sixty-eight patients were diagnosed with occipital neuralgia, which corresponded to 1.2% of the total number of patients (5,515) who visited our Headache Unit during the aforementioned period. Fifty-four (79.4%) of them were female. Baseline pain was present in 62 (91.1%) patients, and exacerbations in 42 (61.8%). Latency from onset (range) was 27.7 ± 56.1 (1-360) months.

CONCLUSIONS

Occipital neuralgia is an uncommon disorder in the sample explored. The prolonged latency between the onset of symptoms and diagnosis suggests that there should be an increased awareness of this disorder.

[Intranasal lidocaine atomization as novel and noninvasive treatment option for postdural puncture headache : Two case reports from obstetric anesthesiology]

Hintergrund

Der Postpunktionskopfschmerz („postdural puncture headache“ [PDPH]) stellt eine ernsthafte anästhesiologische Komplikation geburtshilflich behandelter Patientinnen dar. Führen konservativ-medikamentöse Therapieversuche nicht zu einer Symptomlinderung, empfehlen aktuelle Leitlinien die frühzeitige Durchführung eines epiduralen Blut-Patch. Als potenzielle Alternative wird die transnasale Blockade des Ganglion sphenopalatinum mittels Lokalanästhetika diskutiert.

Methode

In dieser Falldarstellung wird erstmals von einer Modifikation dieser Technik unter Anwendung eines Medikamentenzerstäubers („mucosal atomization device“ [MAD]) zur Therapie eines PDPH bei zwei geburtshilflichen Patientinnen berichtet. Über dieses Verfahren existieren bislang keine Erfahrungen aus der geburtshilflichen Anästhesiologie.

Ergebnisse

Die erste Patientin (25-jährige Zweitgravida, BMI 54,7 kg/m²) zeigte am ersten Tag nach Sectio caesarea in Spinalanästhesie einen ausgeprägten PDPH mit starker Übelkeit und Erbrechen. Bei der zweiten Patientin (32-jährige Drittgravida, BMI 27,3 kg/m²) kam es 4 Tage nach Spontanpartus unter Periduralanästhesie zu einer PDPH-bedingten Wiederaufnahme. Während konservative Maßnahmen sowie Therapieversuche mit Nichtopioidanalgetika und Koffein keinen hinreichenden Behandlungserfolg erzielten, führte die intranasale Lidocainapplikation mittels MAD zu einer unmittelbaren und persistierenden Linderung der Beschwerden. Von beiden Patientinnen wurde die Lidocaingabe sehr gut vertragen; sie konnten am Folgetag aus dem Krankenhaus entlassen werden.

Schlussfolgerung

Die vorgestellte nichtinvasive und einfach durchzuführende Maßnahme stellt eine wertvolle Ergänzung bisheriger Therapieoptionen und eine potenzielle Alternative zum epiduralen Blutpatch bei geburtshilflichen Patientinnen mit PDPH dar.

Role of greater occipital nerve block for preventive treatment of chronic migraine: A critical review

Objective:

The aim of this study is to critically analyze the evidence of the efficacy and safety of greater occipital nerve (GON) block for the preventive treatment of chronic migraine (CM).

Background:

A rigorous scientific assessment of efficacy and safety of the GON block for preventive treatment in CM is not available. This critical review was undertaken for this purpose.

Methods:

References for this review were identified by searches of articles published in the English language in PubMed between 1969 and April 15, 2020 using “greater occipital nerve block,” “chronic migraine,” “migraine,” “headache,” and “treatment” as keywords.

Results:

Out of potential 532 articles, 9 open-label and 4 placebo-controlled trials that studied the role of GON block for prevention of CM were identified and reviewed. Open-label trials reported a reduction of headache severity and frequency in 35–68% of patients. The beneficial effect of a single block lasted up to 4 weeks. Randomized controlled trials (RCTs) used varied methodology and techniques of GON block and the outcomes were reported at different time points. A single RCT showed a beneficial effect of the GON block at 1 week. However, the GON block was found to be safe and well tolerated.

Conclusion:

Long-term efficacy of GON block in CM shall need further well-designed RCTs using standardized methodology. This study, in addition, reviewed the limitations and uncertainties regarding the technique and methods of use of GON block in CM.

Relief of Secondary Headaches with High Thoracic Erector Spinae Plane Block

Intractable headaches can be debilitating, often leading to significant distress, prolonged medical treatment, and unanticipated hospital admissions. There have been significant advances in the treatment of primary intractable headaches such as migraines, tension headaches, and cluster headaches beyond medical management. Treatments may now include interventional strategies such as trigger-point injections, peripheral nerve stimulators, or peripheral nerve and ganglion blocks. There are few studies, however, describing the use of interventional techniques for the management of intractable secondary headaches, including those attributed to injury or infection. A new regional anesthetic technique, the erector spinae plane (ESP) block, was initially used for neuropathic thoracic pain. ESP block has since been reported to provide acute and chronic pain relief of the shoulder, spine, abdomen, pelvis, thorax, and lower extremity. Additionally, there has been one case report to describe the use of the ESP block in the treatment of refractory tension headache. We report four cases of effective analgesia for intractable secondary headache resistant to medical management with high thoracic ESP blocks. In each case, the ESP block provided instant pain relief. We suggest that the findings of this case series indicate that the ESP block may be a useful intervention in patients with severe secondary headache or posterior cervical pain where conventional therapies have limited success, though more studies are necessary.

Effectiveness of Nerve Blocks for the Management of Head and Neck Cancer Associated Neuropathic Pain Disorders; a Retrospective Study

Introduction

A portion of patients with head and neck cancer (HNC)- associated pain may not experience relief in symptoms with non-invasive modalities. A nerve block is a procedure in which a local anaesthetic agent is injected along the nerve track to preferentially block sensory transmission. The literature on the effectiveness of nerve blocks in the management of HNC-related pain is limited. The purpose of this study was to determine the effectiveness of nerve blocks in the management of breakthrough HNC-associated trigeminal or cervical neuropathic pain disorders.

Materials and Methods

A retrospective chart review of patients who underwent a nerve block or infiltration procedure in the regions of head and neck for the management of breakthrough HNC-associated trigeminal or cervical neuropathic pain disorders in the Orofacial Pain Medicine Clinic, Shaukat Khanum Memorial Cancer Hospital and Research Centre, between November 2018 and November 2019 was completed. Information regarding demographics, diagnosis and pain characteristics was extracted and reviewed. The Fisher's exact test and Mann-Whitney U-test were used for analysis between independent and dependent variables.

Results

A total of 27 participants were included in the investigation, of which 66.7% were male. The average pre-procedure pain score was 6.85±2.54. Following intervention, 81.5% of the participants experienced >75% relief in pain for longer than 48 hours. The mean immediate post-procedure pain score was 0.26±1.02 and the average duration of relief was 6.10±6.50 weeks. The significant effect of nerve blocks was found to be statistically associated with the concurrent use of amitriptyline (P = 0.017).

Conclusion

Nerve blocks, as an adjunctive therapy to pharmacologic treatment, can provide significant relief to patients with breakthrough HNC-associated trigeminal and cervical neuropathic pain disorders. However, the duration of relief experienced by the participants is inconsistent. The beneficial effect of nerve blocks appears to be more common in patients that were concurrently using amitriptyline.

Pulsed radiofrequency on the occipital nerve for treatment of short-lasting unilateral neuralgiform headache: A case report

Short-lasting unilateral neuralgiform headache (Short-lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing (SUNCT)/Short-lasting Unilateral Neuralgiform headache attacks with Autonomic Symptoms) is a trigeminal autonomic cephalalgia with difficult treatment and its management is based on neuromodulator drugs and sometimes ablative procedures on the trigeminal nerve. A positive response to occipital anesthetic blocks and peripheral and deep neurostimulation has also been described. We present the case of a patient with criteria of left SUNCT and transient response to occipital anesthetic blocks, satisfactorily controlled with pulsed radiofrequency (PRF) of the occipital nerve. Upon examination, the patient had tenderness in the left greater occipital nerve (GON). Blockade was performed with anesthetic and corticosteroid, obtaining a highly positive but transient response. After several nerve blocks, the patient was referred to the Pain Unit where pulsed radiofrequency on the left GON was performed. After two sessions, more than 90% of reduction of pain was achieved, maintained for 12 months. There haven’t been found data in the literature on the use of GON PRF for the treatment of SUNCT, while there are descriptions for other types of cranial pain. The intention of our case is to make this procedure to be considered as an alternative for the treatment of this entity in patients who respond to anesthetic blocks.

A Proposal for Botulinum Toxin Type A Injection Into the Temporal Region in Chronic Migraine Headache

Botulinum toxin type-A (BTX-A) injection for treating chronic migraine (CM) has developed into a new technique covering distinct injection points in the head and neck regions. The postulated analgesic mechanism implies that the injection should be administered to sensory nerves rather than to muscles. This study aimed to determine the topographical site of the auriculotemporal nerve (ATN) and to propose the effective injection points for treating CM. ATNs were investigated on 36 sides of 25 Korean cadavers. The anatomical structures of the ATN were investigated focusing on the temporal region. A right-angle ruler was positioned based on two clearly identifiable orthogonal reference lines based on the canthus and tragus as landmarks, and photographs were taken. The ATN appeared superficially in the anterosuperior region of the tragus. The nerve is located deeper than the superficial temporal artery. And it runs between the artery and the superficial temporal vein. In the superficial layer, it is divided into anterior and posterior divisions. The anterior division runs in a superior direction, while the posterior division runs in front of the ear and the several branches are distributed to the skin. We suggest that the optimal BTX-A injection points for CM are in the temporal region. The first point is about 2 cm anterior and 3 cm superior to two orthogonal reference lines defined based on the tragus and canthus, and the second point is about 4 cm superior to the first point. The third and fourth points are recommended about 2 cm superior to the first point, but respectively 1 cm anterior and posterior to it.

The Effect of Sphenopalatine Ganglion Block on the Postoperative Pain in Patients Undergoing Septorhinoplasty

OBJECTIVES

This study aimed to evaluate the effect of preoperative sphenopalatine ganglion block (SPBG) on the postoperative pain (POP) in patients undergoing septorhinoplasty (SRP).

METHODS

A retrospective cohort study was performed. A total of 42 patients that had received septorhinoplasty included in the study. The patients that had received SPBG before the surgery included in the Block group (n:20) and the patients that had not received SPBG before the surgery included in the Control group (n:22). POP was questioned with a numeric rating scale (NRS) at the 30th minute (t1), 1st hour (t2), 4th hour (t3), 12th hour (t4), and 24th hour (t5) and noted. The intraoperative details and the dose of the postoperative rescue analgesics were also noted.

RESULTS

The average dose of Paracetamol that was used in the postoperative first 24 hours was 500 mg in the Block group and 1363 mg in the Control group, and the difference was statistically significant (P = .001). The average dose of Tramadol was 0 mg in the Block group and 45 mg in the Control group, and the difference was statistically significant (P = .001). There was a statistically significant difference among the groups with respect to NRS in the first 24 hours postoperatively (P < .05). The number of the patients requiring rescue analgesics was lower in the Block group than the Control group. The difference was statistically significant at the t1, t2, and t5 time intervals (P > .05).

CONCLUSIONS

Preoperative SPGB is an effective option to reduce POP and the need for rescue analgesics for patients undergoing SRP.

CLINICAL TRIAL NUMBER

NCT04020393.

Long-term efficacy of superficial temporal artery ligation and auriculotemporal nerve transection for temporal cluster headache in adolescent

OBJECTIVES

Cluster headache is a primary headache disorder, which has affected up to 0.1% population. Superficial temporal artery ligation combined with auriculotemporal nerve transection (SLAT) is one of the surgical alternatives to treat the drug-resistant temporal cluster headache (TCH). The current work aimed to assess the effect of SLAT on TCH patients based on the very long-term clinical follow-up.

METHODS

The current retrospective study had enrolled 20 adolescent TCH patients undergoing SLAT between December 2016 and January 2018. The headache diaries as well as the pain severity questionnaire of the visual analog scale (VAS) had been collected to measure the pain severity before and after surgery.

RESULTS

The pain-free rates 3 days, as well as 1, 6, and 12 months, after SLAT surgery were 2.00%, 10.00%, 25.00%, and 70.00%, respectively. The frequency of TCH attack daily was found to be markedly reduced on the whole; besides, the pain degree was also remarkably decreased.

CONCLUSIONS

Results in this study indicate that the sustained headache can be relieved after SLAT in adolescent patients with intractable TCH.

Evaluation of Occipital Nerve Blocks for Acute Pain Relief of Migraines

Migraines are a debilitating neurological disease affecting as many as 1 of 6 adults in the United States. Occipital nerve block, consisting of a local anesthetic and/or corticosteroid, has shown to be an effective treatment for the management of migraines. Occipital nerve block has been reported to reduce migraine pain scores, frequency, and duration. We aimed to evaluate the impact of occipital nerve block for acute pain relief in patients with migraines. This was a single-center retrospective observational study conducted at a 1162-bed academic medical center in Gainesville, Florida. Included patients were ≥18 years old, diagnosed with migraine with or without aura, and received at least 1 occipital nerve block. Excluded patients received nerve blocks not specific to the occipital region. The outcomes observed were migraine pain before and after administration within the same initial encounter of receiving an occipital nerve block using a numeric pain rating scale, injection direction, medications used, duration of effect and frequency of additional injections, and adverse reactions. A total of 190 patients met the inclusion criteria, with 63% rating their pain to be 6-8 of 10 prior to an occipital nerve block. After receiving an occipital nerve block, 27% of patients reported significant or immediate relief, and 42% experienced reduced pain scores of 0-2. The majority of injections were bilateral using lidocaine with dexamethasone. Only 3% of patients reported an adverse reaction. Occipital nerve block as adjunctive therapy has shown safety and efficacy in treating patients with migraines, measured by the reduction in pain.

Are repetitive pericranial nerve blocks effective in the management of chronic paroxysmal hemicrania?: A case report

INTRODUCTION

Paroxysmal hemicrania (PH) is a chronic headache disorder characterized by unilateral pain attacks accompanied by cranial autonomic symptoms and responds to indomethacin completely. There are few alternative treatment options for the patients who cannot tolerate indomethacin. Studies exploring the effects of repetitive peripheral cranial nerve blocks in the management of chronic PH are limited.

PATIENT CONCERNS AND DIAGNOSIS

A 34-year-old woman with a 4-year history of PH was evaluated. Her pain was prevented by indomethacin without side effects; however, she wanted to try to conceive.

INTERVENTIONS

Repetitive pericranial nerve blocks, great occipital nerve, infraorbital nerve, supraorbital nerve, and sphenopalatine ganglion block, using local anesthetics and steroids were performed once a week for a 6 weeks period.

OUTCOMES

A follow-up of 3 months showed that there was no pain relief following the injections and patient was needed to be maintained on indomethacin.

CONCLUSION

Although pericranial nerve blocks have been tried in chronic PH cases with positive influences, this case indicated that repetitive nerve blocks were not always a successful therapy option.

Chronic Headache: a Review of Interventional Treatment Strategies in Headache Management

PURPOSE OF THE REVIEW

To provide an overview of current interventional pain management techniques for primary headaches with a focus on peripheral nerve stimulation and nerve blocks.

RECENT FINDINGS

Despite a plethora of treatment modalities, some forms of headaches remain intractable to conservative therapies. Interventional pain modalities have found a niche in treating headaches. Individuals resistant to common regimens, intolerant to pharmaceutical agents, or those with co-morbid factors that cause interactions with their therapies are some instances where interventions could be considered in the therapeutic algorithm. In this review, we will discuss these techniques including peripheral nerve stimulation, third occipital nerve block (TON), lesser occipital nerve block (LON), greater occipital nerve block (GON), sphenopalatine block (SPG), radiofrequency ablation (RFA), and cervical epidural steroid injections (CESI). Physicians have used several interventional techniques to treat primary headaches. While many can be treated pharmacologically, those who continue to suffer from refractory or severe headaches may see tremendous benefit from a range of more invasive treatments which focus on directly inhibiting the painful nerves. While there is a plethora of evidence suggesting these methods are effective and possibly durable interventions, there is still a need for large, prospective, randomized trials to clearly demonstrate their efficacy.

Acute Treatment of Migraine

PURPOSE OF REVIEW

This article provides a framework to help providers formulate a plan for the acute treatment of migraine. Topics covered include the cost-effective patient-centered approach known as stratified care and a summary of evidence-based treatment options that are currently available. Strategies for improving treatment response, troubleshooting suboptimal results, and addressing the needs of special populations are also reviewed.

RECENT FINDINGS

Both the American Headache Society and the Canadian Headache Society have released evidence-based assessments and reviews of acute treatments for migraine that can be used to help guide treatment decisions. Although several older medications have been re-released with new formulations or new delivery systems, several new medications have also become available or are in the final phases of study, further increasing the number of options available for patients.

SUMMARY

The acute management of migraine should incorporate a stratified care model in concert with evidence-based treatment options. The response to treatment should be monitored regularly, and measures should be taken to identify suboptimal tolerability or efficacy.

The Public's Perception of Interventions for Migraine Headache Disorders: A Crowdsourcing Population-Based Study

Background

Migraine disorders are a leading cause of morbidity and decreased economic productivity in the United States among both men and women. As such, it is important to consider patient opinions, and have an accurate representation of the burden and sentiment toward currently available interventions among those suffering from migraines.

Objectives

The aim of the study was to assess patient options regarding adverse outcomes of the various treatment options available for migraine headaches.

Methods

A prospective cross-sectional study of volunteers recruited through an internet crowdsourcing service, Amazon Mechanical Turk©, was conducted. Surveys were administered to collect patient-reported opinions regarding adverse outcomes of both surgical and nonsurgical treatment options for migraine headaches.

Results

The prevalence of migraine headache across all study participants was 15.6% and varied slightly across participant demographics. Individuals ages 35–44 (2.73 migraines per month) experienced the fewest migraine and with the lowest severity. Those individuals ages 45+ experienced the most severe headaches (Visual Analog Scale = 44.23 mm). Additionally, the greatest migraine frequency and severity existed among those households with yearly income of $75,000–$100,000. The lowest injection therapy utility scores were obtained for adverse outcomes of hematoma (47.60 mm) and vertigo (54.40 mm).

Conclusions

Migraine headaches remains a significant problem among the US population, with an overall prevalence of 15.6% (approximately 50 million Americans). Additionally, physicians interesting in offering minimally invasive or surgical treatment for migraine headaches should focus on mitigating patient fears regarding clinical outcomes and cost of care.

Occipital Neuralgia and Cervicogenic Headache: Diagnosis and Management

PURPOSE OF REVIEW

Occipital neuralgia (ON) and cervicogenic headache (CGH) are secondary headache disorders with occipital pain as a key feature. Due to significant phenotypic overlap, differentiating ON and CGH from primary headache disorders such as migraine or tension-type headache, or other secondary headache disorders, can be clinically challenging. This article reviews the anatomy, clinical features, unique diagnostic considerations, and management approaches relating to ON and CGH.

RECENT FINDINGS

Conservative therapeutic approaches are considered first-line. Anesthetic nerve blocks may have a dual role in both supporting diagnosis and providing pain relief. Newer minimally invasive procedures, such as pulsed radiofrequency (PRF) and occipital nerve stimulation (ONS), represent an exciting therapeutic avenue for severe/refractory cases. Surgical interventions should be reserved for select patient populations who have failed all other conservative and minimally invasive options, to be weighed against potential risk. ON and CGH represent an ongoing diagnostic challenge. Further studies are required to consolidate efficacy regarding the comprehensive management of ON and CGH.

Current Approach to Undifferentiated Headache Management in the Emergency Department

PURPOSE OF REVIEW

To discuss pharmacological interventions in the emergency department (ED) setting for the management of acute primary headache.

RECENT FINDINGS

Acute headache treatment in the ED has seen an expansion in terms of possible pharmacological interventions in recent years. After a thorough evaluation ruling out dangerous causes of headache, providers should take the patient's history, comorbidities, and prior therapy into consideration. Antidopaminergics have an established role in the management of acute, severe, headache with manageable side-effect profiles. However, recent studies suggest anesthetic and anti-epileptic drugs may play roles in headache treatment in the ED. Current literature also suggest steroids as a promising tool for emergency department clinicians combating the readmission of patients with recurrent headaches. Emergency medicine providers must be cognizant of these traditional and emerging therapies in order to optimize the care of headache patients.

Greater palatine block for V2 trigeminal neuralgia: Case report

AIMS

This study describes a novel nerve block directed at the maxillary (V2) division of the fifth cranial nerve as treatment for medication-refractory trigeminal neuralgia (TN).

METHODS AND RESULTS

The authors present three cases of TN treated with V2 nerve block using commonly available local anesthetics injected through the greater palatine foramen. Patients' medications were noted before and after the procedure. Following the injection, patients were followed over time and outcome was assessed. Patients experienced rapid and long-lasting pain relief allowing for significant reduction in antineuralgia medications. This was done with the objective of breaking the pain cycle with subsequent discontinuation or reduction of analgesic medications.

CONCLUSION

This technique may be an effective treatment for medication-refractory V2 TN. By interrupting the pain cycle, this renders the condition amenable to long-term control using diminished doses of standard antineuralgia pharmaceuticals. The practical implications of the described procedure are that it is simple, safe, and well-tolerated with few or no adverse effects. This novel technique is a diagnostic feature for the dentist to differentiate between sources of facial pain.

Greater occipital nerve block in migraine prophylaxis: Narrative review

Objectives

The importance and popularity of peripheral nerve block procedures have increased in the treatment of migraine. Greater occipital nerve (GON) block is a commonly used peripheral nerve block method, and there are numerous researches on its use in migraine treatment.

Materials and methods

A search of PubMed for English-language randomized controlled trials (RCT) and open studies on greater occipital nerve block between 1995 and 2018 was performed using greater occipital nerve, headache, and migraine as keywords.

Results

In total, 242 potentially relevant PubMed studies were found. A sum of 228 of them which were non-English articles and reviews, case reports, letters and meta-analyses were excluded. The remaining articles were reviewed, and 14 clinical trials, seven of which were randomized-controlled on greater occipital nerve block in migraine patients, were identified and reviewed.

Conclusions

Although clinicians commonly use greater occipital nerve block in migraine patients, the procedure has yet to be standardized. The present study reviewed the techniques, drugs and dosages, the frequency of administration, side effects, and efficacy of greater occipital nerve block in migraine patients.

Influence of patient positioning on reported clinical outcomes after greater occipital nerve block for treatment of headache: Results from prospective single-centre, non-randomised, proof-of-concept study

OBJECTIVE

Greater occipital nerve (GON) block is a treatment option applied for a variety of primary headache disorders. Although a patient's body position is known to have an impact on the effect of local anaesthetics, this has not before been investigated for patients undergoing GON block. Therefore, the clinical effectiveness of either a sitting or supine position was assessed.

PATIENTS AND METHODS

This evaluative prospective study took place in a single neurology department in the UK. Baseline and follow-up data were collated during standard clinic consultations for 95 consecutive patients who underwent GON block and follow-up consultations for treatment-refractory headache disorder. The GON block procedure was identical for all patients in terms of constitution of the applied medication and volume injected (lidocaine hydrochloride 20 mg and methylprednisolone acetate 80 mg in 2 ml vial). Directly afterwards, patients opted to either sit up (n = 34) or lie down (n = 61) for ten minutes.

RESULTS

Twenty-seven patients (44%) reported substantial benefit and 17 (28%) complete benefit (pain freedom) for a median duration of 70 days and 84 days in the 'supine' group, compared with 10 (29%) substantial and 6 (18%) complete benefit (pain freedom) for a median duration of 25 days (substantial) and 119 days (complete) in the 'sitting' group. Overall, a supine position results in a longer overall post-GON block headache-free period (p-value 0.007) and median relief score (p-value 0.017) compared to a sitting up position, as determined by Mann-Whitney U-test. Backward multiple linear regression analysis showed that the chronicity of the patient's condition is negatively associated (beta -0.24, p-value 0.024) and the post-GON block patient position is positively associated (beta 0.25, p-value 0.018) with the achieved headache-free period. Apart from variation in baseline headache characteristics, the 'sitting' and 'supine' cohorts did not significantly differ in terms of other clinical parameters and patient demographics.

CONCLUSIONS

Placing a patient in a supine position following a GON block procedure for headache may significantly improve the resulting clinical effectiveness of this treatment. Further research, through a prospective, multi-centre, randomised, controlled trial, is indicated to determine if the initial positive observations in this present pragmatic evaluation can be confirmed.

Efficacy of bilateral greater occipital nerve block in postdural puncture headache: a narrative review

The Epidural blood patch is considered the gold standard for managing postdural puncture headache when supportive measures fail. However, it is a procedure which can lead to another inadvertent dural puncture. Other potential adverse events that could occur during a blood patch are meningitis, neurological deficits, and unconsciousness. The bilateral greater occipital nerve block has been used for treating chronic headaches in patients with PDPH with a single injection. This minimally invasive, simple procedure can be considered for patients early, along with other supportive treatment, and an epidural blood patch can be avoided.

Measurement and implications of the distance between the sphenopalatine ganglion and nasal mucosa: a neuroimaging study

BACKGROUND

Historical reports describe the sphenopalatine ganglion (SPG) as positioned directly under the nasal mucosa. This is the basis for the topical intranasal administration of local anaesthetic (LA) towards the sphenopalatine foramen (SPF) which is hypothesized to diffuse a distance as short as 1 mm. Nonetheless, the SPG is located in the sphenopalatine fossa, encapsulated in connective tissue, surrounded by fat tissue and separated from the nasal cavity by a bony wall. The sphenopalatine fossa communicates with the nasal cavity through the SPF, which contains neurovascular structures packed with connective tissue and is covered by mucosa in the nasal cavity. Endoscopically the SPF does not appear open. It has hitherto not been demonstrated that LA reaches the SPG using this approach.

METHODS

Our group has previously identified the SPG on 3 T-MRI images merged with CT. This enabled us to measure the distance from the SPG to the nasal mucosa covering the SPF in 20 Caucasian subjects on both sides (n = 40 ganglia). This distance was measured by two physicians. Interobserver variability was evaluated using the intraclass correlation coefficient (ICC).

RESULTS

The mean distance from the SPG to the closest point of the nasal cavity directly over the mucosa covering the SPF was 6.77 mm (SD 1.75; range, 4.00-11.60). The interobserver variability was excellent (ICC 0.978; 95% CI: 0.939-0.990, p < 0.001).

CONCLUSIONS

The distance between the SPG and nasal mucosa over the SPF is longer than previously assumed. These results challenge the assumption that the intranasal topical application of LA close to the SPF can passively diffuse to the SPG.

Headache

Headache, an almost universal human experience, is one of the most common complaints encountered in medicine and neurology. Described and categorized since antiquity, with the first classification by Aretaeus of Cappadocia, other classifications followed. The evaluation of this condition may be straightforward or challenging, and, though often benign, headache may prove to be an ominous symptom. This review discusses the current diagnosis and classification of headache disorders and principles of management, with a focus on migraine, tension-type headache, trigeminal autonomic cephalgias, and various types of daily headache.

Ganglion blocks as a treatment of pain: current perspectives

The inputs from sympathetic ganglia have been known to be involved in the pathophysiology of various painful conditions such as complex regional pain syndrome, cancer pain of different origin, and coccygodynia. Sympathetic ganglia blocks are used to relieve patients who suffer from these conditions for over a century. Many numbers of local anesthetics such as bupivacaine or neurolytic agents such as alcohol can be chosen for a successful block. The agent is selected according to its duration of effect and the purpose of the injection. Most commonly used sympathetic blocks are stellate ganglion block, lumbar sympathetic block, celiac plexus block, superior hypogastric block, and ganglion Impar block. In this review, indications, methods, effectiveness, and complications of these blocks are discussed based on the data from the current literature.

Injection Therapy for Headache and Facial Pain

Peripheral nerve blocks are an increasingly viable treatment option for selected groups of headache patients, particularly those with intractable headache or facial pain. Greater occipital nerve block, the most widely used local anesthetic procedure in headache conditions, is particularly effective, safe, and easy to perform in the office. Adverse effects are few and infrequent. These procedures can result in rapid relief of pain and allodynia, and effects last for several weeks or months. Use of nerve block procedures and potentially onabotulinum toxin therapy should be expanded for patients with intractable headache disorders who may benefit, although more studies are needed for efficacy and clinical safety.