Occipital Nerve Blocks in Postconcussive Headaches

Dynamic in vivo 3D atlantooccipital kinematics during multiplanar physiologic motions

Normal biomechanics of the upper cervical spine, particularly at the atlantooccipital joint, remain poorly characterized. The purpose of this study was to determine the intervertebral kinematics of the atlantooccipital joint (occiput-C1) during three-dimensional in vivo physiologic movements. Twenty healthy young adults performed dynamic flexion/extension, axial rotation, and lateral bending while biplane radiographs were collected at 30 images per second. Motion at occiput-C1 was tracked using a validated volumetric model-based tracking process that matched subject-specific CT-based bone models to the radiographs. The occiput-C1 total range of motion (ROM) and helical axis of motion (HAM) was calculated for each movement. During flexion/extension, the occiput-C1 moved almost exclusively in-plane (ROM: 17.9 ± 6.9°) with high variability in kinematic waveforms (6.3°) compared to the in-plane variability during axial rotation (1.4°) and lateral bending (0.9°) movements. During axial rotation, there was small in-plane motion (ROM: 4.2 ± 2.5°) compared to out-of-plane flexion/extension (ROM: 12.7 ± 5.4°). During lateral bending, motion occurred in-plane (ROM: 9.0 ± 3.1°) and in the plane of flexion/extension (ROM: 7.3 ± 2.7°). The average occiput-C1 axis of rotation intersected the sagittal and coronal planes 7 mm to 18 mm superior to the occipital condyles. The occiput-C1 axis of rotation pointed 60° from the sagittal plane during axial rotation but only 10° from the sagittal plane during head lateral bending. These novel results are foundational for future work on upper cervical spine kinematics.

The Postconcussion Syndrome and Posttraumatic Headaches in Civilians, Soldiers, and Athletes

Posttraumatic headaches are one of the most common and controversial secondary headache types. After a mild traumatic brain, an estimated 11% to 82% of people develop a postconcussion syndrome, which has been controversial for more than 160 years. Headache is estimated as present in 30% to 90% of patients after a mild head injury. Most headaches are tension-type-like or migraine-like. Headaches in civilians, soldiers, athletes, and postcraniotomy are reviewed. The treatments are the same as for the primary headaches. Persistent posttraumatic headaches can continue for many years.

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.

Occipital Neuralgia May Be a Possible Limitation on the Utility of the Buffalo Treadmill Test for Concussion Assessments: 2 Case Reports

ABSTRACT

Two female athletes presented to clinic following a head injury and exhibited signs of concussion. Both athletes experienced exacerbation of symptoms secondary to dysautonomia related to concussion injury on the Buffalo Concussion Treadmill Test (BCTT). On repeat evaluation, both athletes exhibited neck pain with symptoms immediately provoked by palpation of the occipital nerves. After a third occipital nerve block, both athletes had complete resolution of symptoms and subsequently tolerated BCTT to the maximum rate of perceived exertion with no provoked symptoms. The athletes were cleared for return to sport without issue. These cases indicate a potential limitation in the utility of the BCTT for determining the etiology and management of concussion and postconcussion syndrome.

Cranial Neuralgias in Children and Adolescents A review of the literature

Cranial neuralgias are a well-established cause of headache-related morbidity in the adult population. These disorders are poorly studied in general due to their relative rarity, particularly in children and adolescents, and they are likely underdiagnosed in these populations. Recognizing these disorders and differentiating them from more common headache disorders, such as migraine, is important, as secondary disease is common. This review will cover the basic epidemiology, diagnosis, and treatment of trigeminal, occipital, glossopharyngeal and other, less common, cranial neuralgias. We have reviewed pediatric case reports of these conditions. For trigeminal neuralgia, the most common of these disorders, we have compiled the clinical features and treatment response of previous reports.

Role of Greater Occipital Nerve Block in Headache Disorders: A Narrative Review

Background

The proximity of sensory neurons in the upper cervical spinal cord to the trigeminal nucleus caudalis (TNC) neurons and the convergence of sensory input to TNC neurons from both cervical and trigeminal fibers underscore the rationale of using greater occipital nerve block (GON-block) for acute and preventive treatment in various headache disorders.

Objective

The aim of this study was to critically review the existing literature regarding the safety and efficacy of GON-block in various headache disorders.

Methods

We searched the eligible studies in English by searching in PubMed till December 31, 2020 for randomized controlled trials (RCTs), observational studies, open-label studies, case series, and case reports on the efficacy and the safety of GON-block for the treatment of headache disorders using the keywords "greater occipital nerve block", "headache" and "treatment". Studies using combination of GON-block and other peripheral nerve blocks (PNBs) and C2/C3 blocks were excluded.

Results

Seventy-two eligible studies were reviewed. Based on RCTs and open-label studies, good evidence of the efficacy of GON-block was found for migraine, cluster headache (CH), post-dural puncture headache (PDPH), cervicogenic headache (CGH), and occipital neuralgia (ON). The analgesic effect of GON-block outlasted its anesthetic effect by days to weeks. Evidence for acute and short-term (transitional) treatment was more robust than for long-term prevention. GON-block was found to be safe and the treatment-emergent adverse effects (TEAEs) were generally mild and transient.

Conclusion

GON-block is a useful modality of treatment in various headache disorders because of many attractive features such as its early effect in reducing the severity of pain, sustained effect following a single injection, easy technique, minimum invasiveness, minimum TEAE, no drug-to-drug interactions, and negligible cost.

Rehabilitation of Sport-Related Concussion

This article provides a summary of clinical assessment methods and nonpharmacologic rehabilitation techniques used for concussed patients. It describes concussion-relevant physical examination methods to identify underlying symptom generators. This approach allows practitioners to prescribe targeted rehabilitation therapies to treat postconcussion symptoms. Evidence-based rehabilitation approaches include cervical rehabilitation, vestibulo-ocular rehabilitation, and sub-symptom threshold aerobic exercise.

Post-traumatic cephalalgia

After traumatic brain injury (TBI), a host of symptoms of varying severity and associated functional impairment may occur. One of the most commonly encountered and challenging to treat are the post-traumatic cephalalgias. Post-traumatic cephalalgia (PTC) or headache is often conceptualized as a single entity as currently classified using the ICHD-3. Yet, the terminology applicable to the major primary, non-traumatic, headache disorders such as migraine, tension headache, and cervicogenic headache are often used to specify the specific type of headache the patients experiences seemingly disparate from the unitary definition of post-traumatic headache adopted by ICHD-3. More complex post-traumatic presentations attributable to brain injury as well as other headache conditions are important to consider as well as other causes such as medication overuse headache and medication induced headache. Treatment of any post-traumatic cephalalgia must be optimized by understanding that there may be more than one headache pain generator, that comorbid traumatic problems may contribute to the pain presentation and that pre-existing conditions could impact both symptom complaint, clinical presentation and recovery. Any treatment for PTC must harmonize with ongoing medical and psychosocial aspects of recovery.

Post Traumatic Headache: Clinical care of athletes vs non athletes with Persistent Post Traumatic Headache after Concussion: Sports Neurologist and Headache Specialist Perspective

PURPOSE

The purpose of this paper is to review and outline the similarities and differences in the treatment of athletes compared with that of other populations with a persistent post-traumatic headache after a concussion.

RECENT FINDINGS

After an extensive review of the literature and despite well over 2 million Americans experiencing post-traumatic headache (PTH) each year, a number of which will continue to experience persistent post-traumatic headache (PPTH). There is little evidence on the management of the disorder and essentially no evidence-based research when it comes to the management of athletes. With little evidence available for the treatment of individuals with PPTH, be it athletes or non-athletes, the clinician will need to rely on their experience and the application of existing treatments for migraine and chronic migraine. Clearly, more research is needed, especially with respect to the management of athletes versus non-athletes.

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.

Practice Current: How do you diagnose and treat post-concussive headache?

A common complaint after concussion is the development of new or worsening headaches which can make it difficult or even impossible for patients to work or function in their day-to-day lives. Uncertainties associated with the complaints and a wide variety of approaches exist regarding the appropriate work-up and management of these patients. Areas of ongoing debate include the need for neuroimaging; optimal, acute, and preventative treatment; and proper counseling and expectation management. Given the wide variety of potential approaches and the lack of consensus, we sought expert opinion from around the globe on how to evaluate and manage patients with headache following concussion. Similar questions were posed to the rest of our readership in an online survey (links.lww.com/CPJ/A96), the results of which are also presented.

Concussion part II: Rehabilitation - The need for a multifaceted approach

INTRODUCTION

While most individuals recover in the initial days to weeks following a concussion, in up to 30% of cases symptoms and functional limitations may persist beyond the initial four weeks. There is emerging evidence that multifaceted physiotherapy techniques for individuals who have ongoing symptoms following concussion may be of benefit.

PURPOSE

The purpose of this masterclass article is to summarize the evidence for rehabilitation, describe treatment techniques and multifaceted interventions following concussion.

IMPLICATIONS

Concussion is a heterogenous injury and multiple types of rehabilitation may be required to address ongoing alterations in function. A greater understanding of evidence based rehabilitative techniques will enable the clinician to direct treatment and facilitate recovery for individuals who have ongoing symptoms following concussion.

Management of Chronic Migraine and Occipital Neuralgia in Post 9/11 Combat Veterans

Introduction

The rate of chronic migraine (CM) has been shown to be 20% or greater in the post 9/11 combat veteran population with a history of traumatic brain injury, while the rate is much lower at 3–5% in the general population. Studies have shown that medications such as oral topiramate or intramuscular injections of onabotulinum toxin A (Botox) have been used for CM prevention, and occipital blocks have been shown to be helpful in treating occipital neuralgia and short-term relief of CM. However, there are no known studies that have specifically evaluated the use of Botox and occipital blocks for reducing headache frequency in the US veteran population. The purpose of this study was to evaluate the effectiveness of using occipital blocks and Botox as dual therapy for reducing headache frequency in post 9/11 combat veterans with CM, occipital neuralgia, and a history of TBI or neck trauma.

Materials and Methods

Following Institutional Review Board approval, a retrospective chart review was completed on post 9/11 combat veterans treated in a headache clinic located at the Central Texas Veteran Health Care System. The electronic medical record was used to retrieve the charts of post 9/11 combat veterans who (1) had a confirmed deployment-related history of TBI or neck trauma; (2) were diagnosed with CM and occipital neuralgia; and (3) were treated in the headache clinic between January 1, 2014 and December 31, 2015 with the administration of occipital blocks and Botox within the first six months. Of 282 charts that were reviewed, a total of 30 (N = 30) veterans fit the criteria. The mean number of self-reported headache days per month (28 days) for the month prior to starting treatment was compared to the number of headache days per month (28 days) 6 months after initiation of therapy.

Results

Results revealed that the mean number of headache days in the month prior to treatment was 24.1 (22.0, 25.7). The mean number of headache days in the month post-treatment (6 months after the initiation of dual therapy with occipital blocks and Botox) was 12.9 (9.7, 16.4). The mean difference in the number of headache days from pre- to post-treatment (pre-treatment minus post-treatment) was 11.2 (8.2, 14.2).

Conclusion

This study evaluated the effectiveness of using occipital blocks and Botox as dual therapy for reducing headache frequency for post 9/11 combat veterans with CM, occipital neuralgia, and a history of TBI or neck trauma. Results revealed a statistically significant reduction in the number of headache days per month after the dual therapy. There were multiple limitations to the study to include a small sample size, lack of a control group, self-reported headaches for only 1 month pre-and post-treatment, and no control for other interventions or events which may have influenced the outcome. There is a strong need for randomized, double blinded, placebo- controlled studies involving dual therapy in this population. This study, though small, may be helpful in stimulating additional studies and treatments in this veteran population.

Neck Injury Comorbidity in Concussion-Related Emergency Department Visits: A Population-Based Study of Sex Differences Across the Life Span

Background: The cervical spine region can be especially vulnerable to concurrent injury in concussion, with research suggesting that females may be at greater risk due to their weaker and anatomically distinct necks. The main objective of our research was to study sex differences in the rate of neck injury comorbidity across the life span among patients with a concussion diagnosis in the emergency department (ED) setting, by cause of injury (motor vehicle collisions [MVC] and sports).

Materials and Methods: All patients with a first concussion-related ED visit between fiscal years 2002/2003 and 2011/2012 (inclusive) in Ontario were identified in population-based health administrative data using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Canada (ICD-10-CA) codes. Age-dependent odds ratios of comorbid neck injury for sex were estimated using polynomial multivariable logistic regression models, adjusting for sociodemographic characteristics.

Results: Females with a concussion had significantly higher odds of sustaining a comorbid neck injury between the ages of 5–49 years for all concussion-related ED visits, 15–49 years for MVC-related concussion ED visits, and 10–39 years for sports-related concussion ED visits, holding all other covariates in the model constant.

Conclusions: These results support the consideration of increased screening for comorbid neck injuries, particularly for females, to allow for early intervention. Furthermore, the increased risk of comorbid neck injury in females with a concussion-related ED visit was age-dependent, with the interaction between sex and age following a nonlinear trend. As such, future studies on concussions should consider linear and nonlinear sex and age interactions.

Occipital Neuralgia: a noninvasive therapeutic approach

Objective:

to evaluate the application of a noninvasive intervention consisting of a postural modification using personalized models and osteopathy in people with occipital neuralgia.

Method:

retrospective study of the intervention performed in adult population with occipital neuralgia, consisting of postural modification using personalized plantar orthoses and osteopathy, in a study period of four years. The observed variables were: persistence of headache, alignment of the axes, plantar support, center of gravity and center of mass; medical interview data, visual analogue scale, Win-Track gait analysis system and Kinovea software for video analysis (clinical assessment instruments used).

Results:

a total of 34 records of people with occipital neuralgia were studied. A fraction of 58.8% of the patients reported improvement after the intervention. The visual analogue scale data were provided for 64.7% of the records and significant differences (p <0.001) between the means before (8.4 ± 1.7) and after the intervention (2.6 ± 2.7) were found.

Conclusion:

postural modification using personalized orthoses and osteopathy substantially improves the symptomatology of patients with occipital neuralgia.

Dynamic in vivo 3D atlantoaxial spine kinematics during upright rotation

Diagnosing dysfunctional atlantoaxial motion is challenging given limitations of current diagnostic imaging techniques. Three-dimensional imaging during upright functional motion may be useful in identifying dynamic instability not apparent on static imaging. Abnormal atlantoaxial motion has been linked to numerous pathologies including whiplash, cervicogenic headaches, C2 fractures, and rheumatoid arthritis. However, normal C1/C2 rotational kinematics under dynamic physiologic loading have not been previously reported owing to imaging difficulties. The objective of this study was to determine dynamic three-dimensional in vivo C1/C2 kinematics during upright axial rotation. Twenty young healthy adults performed full head rotation while seated within a biplane X-ray system while radiographs were collected at 30 images per second. Six degree-of-freedom kinematics were determined for C1 and C2 via a validated volumetric model-based tracking process. The maximum global head rotation (to one side) was 73.6±8.3°, whereas maximum C1 rotation relative to C2 was 36.8±6.7°. The relationship between C1/C2 rotation and head rotation was linear through midrange motion (±20° head rotation from neutral) in a nearly 1:1 ratio. Coupled rotation between C1 and C2 included 4.5±3.1° of flexion and 6.4±8.2° of extension, and 9.8±3.8° of contralateral bending. Translational motion of C1 relative to C2 was 7.8±1.5mm ipsilaterally, 2.2±1.2mm inferiorly, and 3.3±1.0mm posteriorly. We believe this is the first study describing 3D dynamic atlantoaxial kinematics under true physiologic conditions in healthy subjects. C1/C2 rotation accounts for approximately half of total head axial rotation. Additionally, C1 undergoes coupled flexion/extension and contralateral bending, in addition to inferior, lateral and posterior translation.

Interventional Treatment for Post-traumatic Headache

Post-traumatic headache (migraine) is the most common symptom of concussion and traumatic brain injury. An expert opinion-based review along with a literature review (PubMed) was conducted looking at known interventional procedures for post-traumatic headache using the keywords post-traumatic headache, post-traumatic migraine headache, concussion, mild traumatic brain injury, and traumatic brain injury and the following categories: mechanism, pathophysiology, treatment, physical therapy, neurostimulation, Botox@/Onabotulinum toxin, and surgical intervention. The results returned a total of 181 articles of which 52 were selected. None of the articles included randomized placebo-controlled studies, and most were either prospective or retrospective case analysis and/or review articles or consensus opinion papers, with most studies yielding positive results. Despite a lack of hard evidence, interventional procedures, alone or in combination, appear to be an effective treatment for post-traumatic headaches.

Randomized, double-blind, comparative-effectiveness study comparing pulsed radiofrequency to steroid injections for occipital neuralgia or migraine with occipital nerve tenderness

Occipital neuralgia (ON) is characterized by lancinating pain and tenderness overlying the occipital nerves. Both steroid injections and pulsed radiofrequency (PRF) are used to treat ON, but few clinical trials have evaluated efficacy, and no study has compared treatments. We performed a multicenter, randomized, double-blind, comparative-effectiveness study in 81 participants with ON or migraine with occipital nerve tenderness whose aim was to determine which treatment is superior. Forty-two participants were randomized to receive local anesthetic and saline, and three 120 second cycles of PRF per targeted nerve, and 39 were randomized to receive local anesthetic mixed with deposteroid and 3 rounds of sham PRF. Patients, treating physicians, and evaluators were blinded to interventions. The PRF group experienced a greater reduction in the primary outcome measure, average occipital pain at 6 weeks (mean change from baseline -2.743 ± 2.487 vs -1.377 ± 1.970; P < 0.001), than the steroid group, which persisted through the 6-month follow-up. Comparable benefits favoring PRF were obtained for worst occipital pain through 3 months (mean change from baseline -1.925 ± 3.204 vs -0.541 ± 2.644; P = 0.043), and average overall headache pain through 6 weeks (mean change from baseline -2.738 ± 2.753 vs -1.120 ± 2.1; P = 0.037). Adverse events were similar between groups, and few significant differences were noted for nonpain outcomes. We conclude that although PRF can provide greater pain relief for ON and migraine with occipital nerve tenderness than steroid injections, the superior analgesia may not be accompanied by comparable improvement on other outcome measures.

Multi-Disciplinary Management of Athletes with Post-Concussion Syndrome: An Evolving Pathophysiological Approach

Historically, patients with sports-related concussion (SRC) have been managed in a uniform fashion consisting mostly of prescribed physical and cognitive rest with the expectation that all symptoms will spontaneously resolve with time. Although this approach will result in successful return to school and sports activities in the majority of athletes, an important proportion will develop persistent concussion symptoms characteristic of post-concussion syndrome (PCS). Recent advances in exercise science, neuroimaging, and clinical research suggest that the clinical manifestations of PCS are mediated by unique pathophysiological processes that can be identified by features of the clinical history and physical examination as well as the use of graded aerobic treadmill testing. Athletes who develop PCS represent a unique population whose care must be individualized and must incorporate a rehabilitative strategy that promotes enhanced recovery of concussion-related symptoms while preventing physical deconditioning. In this review, we present our evolving evidence-based approach to evaluation and management of athletes with PCS that aims to identify the pathophysiological mechanisms mediating persistent concussion symptoms and guides the initiation of individually tailored rehabilitation programs that target these processes. In addition, we outline the important qualified roles that multi-disciplinary healthcare professionals can play in the management of this patient population, and discuss where future research efforts must be focused to further evaluate this evolving pathophysiological approach.

Cervical Spine Involvement in Mild Traumatic Brain Injury: A Review

Background. There is a lack of scientific evidence in the literature on the involvement of the cervical spine in mTBI; however, its involvement is clinically accepted. Objective. This paper reviews evidence for the involvement of the cervical spine in mTBI symptoms, the mechanisms of injury, and the efficacy of therapy for cervical spine with concussion-related symptoms. Methods. A keyword search was conducted on PubMed, ICL, SportDiscus, PEDro, CINAHL, and Cochrane Library databases for articles published since 1990. The reference lists of articles meeting the criteria (original data articles, literature reviews, and clinical guidelines) were also searched in the same databases. Results. 4,854 records were screened and 43 articles were retained. Those articles were used to describe different subjects such as mTBI's signs and symptoms, mechanisms of injury, and treatments of the cervical spine. Conclusions. The hypothesis of cervical spine involvement in post-mTBI symptoms and in PCS (postconcussion syndrome) is supported by increasing evidence and is widely accepted clinically. For the management and treatment of mTBIs, few articles were available in the literature, and relevant studies showed interesting results about manual therapy and exercises as efficient tools for health care practitioners.

Concussion is confusing us all

It is time to stop using the term concussion as it has no clear definition and no pathological meaning. This confusion is increasingly problematic as the management of ‘concussed’ individuals is a pressing concern. Historically, it has been used to describe patients briefly disabled following a head injury, with the assumption that this was due to a transient disorder of brain function without long-term sequelae. However, the symptoms of concussion are highly variable in duration, and can persist for many years with no reliable early predictors of outcome. Using vague terminology for post-traumatic problems leads to misconceptions and biases in the diagnostic process, producing uninterpretable science, poor clinical guidelines and confused policy. We propose that the term concussion should be avoided. Instead neurologists and other healthcare professionals should classify the severity of traumatic brain injury and then attempt to precisely diagnose the underlying cause of post-traumatic symptoms.

Occipital Nerve Blocks for Pediatric Posttraumatic Headache: A Case Series

Posttraumatic headache is one of the most common and disabling symptoms after traumatic brain injury. However, evidence for treating posttraumatic headache is sparse, especially in the pediatric literature. This retrospective chart review evaluated the use of occipital nerve blocks in adolescents treated for posttraumatic headache following mild traumatic brain injury, presenting to the Complex Concussion and Traumatic Brain Injury clinic. Fifteen patients (mean age 15.47; range: 13-17) received occipital nerve block for posttraumatic headache. Follow-up was obtained in 14 patients at 5.57 (standard deviation = 3.52) months postinjury. The headache burden was high, with all except one having headaches 15 or more days per month (median 30, range 10-30). Sixty-four percent reported long-term response to the occipital nerve blocks, with associated improved quality of life and decreased postconcussion symptom scores (P < .05). One patient reported transient allopecia. Occipital nerve blocks are well tolerated and can be helpful in posttraumatic headache.

Part II--Management of pediatric post-traumatic headaches

BACKGROUND

Post-traumatic headache is one of the most common symptoms occurring after mild traumatic brain injury in children.

METHODS

This is an expert opinion-based two-part review on pediatric post-traumatic headaches. In part II, we focus on the medical management of post-traumatic headaches. There are no randomized controlled trials evaluating the efficacy of therapies specifically for pediatric post-traumatic headaches. Thus, the algorithm we propose has been extrapolated from the primary headache literature and small noncontrolled trials of post-traumatic headache.

RESULTS

Most post-traumatic headaches are migraine or tension type, and standard medications for these headache types are used. A multifaceted approach is needed to address all the possible causes of headache and any comorbid conditions that may delay recovery or alter treatment choices. For acute treatment, nonsteroidal anti-inflammatories can be used. If the headaches have migrainous features and nonsteroidal anti-inflammatories are not effective, triptans may be beneficial. Opioids are not indicated. Medication overuse should be avoided. For preventive treatments, some reports indicate that amitriptyline, gabapentin, or topiramate may be beneficial. Amitriptyline is a good choice because it can be used to treat both migraine and tension-type headaches. Nerve blocks, nutraceuticals (e.g. melatonin), and behavioral therapies may also be useful, and lifestyle factors, especially adequate sleep hygiene and strategies to cope with anxiety, should be emphasized.

CONCLUSIONS

Improved treatment of acute post-traumatic headache may reduce the likelihood of developing chronic headaches, which can be especially problematic to effectively manage and can be functionally debilitating.

Occipital neuralgia: anatomic considerations

Occipital neuralgia is a debilitating disorder first described in 1821 as recurrent headaches localized in the occipital region. Other symptoms that have been associated with this condition include paroxysmal burning and aching pain in the distribution of the greater, lesser, or third occipital nerves. Several etiologies have been identified in the cause of occipital neuralgia and include, but are not limited to, trauma, fibrositis, myositis, fracture of the atlas, and compression of the C-2 nerve root, C1-2 arthrosis syndrome, atlantoaxial lateral mass osteoarthritis, hypertrophic cervical pachymeningitis, cervical cord tumor, Chiari malformation, and neurosyphilis. The management of occipital neuralgia can include conservative approaches and/or surgical interventions. Occipital neuralgia is a multifactorial problem where multiple anatomic areas/structures may be involved with this pathology. A review of these etiologies may provide guidance in better understanding occipital neuralgia.

Posttraumatic headaches in civilians, soldiers, and athletes

Posttraumatic headaches are one of the most common and controversial secondary headache types. After mild head injury, more than 50% of people develop a postconcussion syndrome which has been controversial for more than 150 years. Headache is estimated as present in 30% to 90% of patients after mild head injury. Most headaches are of the tension type, although migraines can increase in frequency or occur acutely or chronically de novo. A review is provided of headaches in civilians, soldiers after blast trauma, athletes, and post-craniotomy including pathogenesis. The treatments are the same as for the primary phenotypes.

A guide to diagnoses, indications, and contraindications for interventions in pediatric chronic pain

Although the painful conditions in children and young adults do not involve a broad spectrum of disorders, the treatment itself may pose a challenge. Taking care of psychosocial factors is equally important as taking care of physical aspects. Our simple suggestion is to start with basics and advance to more complex treatments if needed. Please review Figure 2 for suggested treatment algorithms.

Expert consensus recommendations for the performance of peripheral nerve blocks for headaches--a narrative review

OBJECTIVE

To describe a standardized methodology for the performance of peripheral nerve blocks (PNBs) in the treatment of headache disorders.

BACKGROUND

PNBs have long been employed in the management of headache disorders, but a wide variety of techniques are utilized in literature reports and clinical practice.

METHODS

The American Headache Society Special Interest Section for PNBs and other Interventional Procedures convened meetings during 2010-2011 featuring formal discussions and agreements about the procedural details for occipital and trigeminal PNBs. A subcommittee then generated a narrative review detailing the methodology.

RESULTS

PNB indications may include select primary headache disorders, secondary headache disorders, and cranial neuralgias. Special procedural considerations may be necessary in certain patient populations, including pregnancy, the elderly, anesthetic allergy, prior vasovagal attacks, an open skull defect, antiplatelet/anticoagulant use, and cosmetic concerns. PNBs described include greater occipital, lesser occipital, supratrochlear, supraorbital, and auriculotemporal injections. Technical success of the PNB should result in cutaneous anesthesia. Targeted clinical outcomes depend on the indication, and include relief of an acute headache attack, terminating a headache cycle, and transitioning out of a medication-overuse pattern. Reinjection frequency is variable, depending on the indications and agents used, and the addition of corticosteroids may be most appropriate when treating cluster headache.

CONCLUSIONS

These recommendations from the American Headache Society Special Interest Section for PNBs and other Interventional Procedures members for PNB methodology in headache disorder treatment are derived from the available literature and expert consensus. With the exception of cluster headache, there is a paucity of evidence, and further research may result in the revision of these recommendations to improve the outcome and safety of these interventions.

Posttraumatic headache

Headache is a common symptom after traumatic head injury and is a frequent feature of the postconcussive syndrome. A variety of headache subtypes can be precipitated by head trauma, although posttraumatic headaches most often resemble migraine or tension-type headache. A lack of clinical trials limits evidence-based treatment recommendations for both acute and chronic posttraumatic headaches. However, numerous pharmacologic and nonpharmacologic interventions can be used to successfully manage posttraumatic headaches. This article reviews the classification, epidemiology, prognosis, and pathophysiology of headaches after head trauma and provides a practical clinical approach for evaluating and treating patients with posttraumatic headaches.

Posttraumatic headache in military personnel and veterans of the iraq and afghanistan conflicts

OPINION STATEMENT

Headaches, particularly migraine, are common in US servicemembers (SMs) who are deployed to or have returned from theaters of combat operations in Iraq and Afghanistan. Concussions and exposure to explosive blasts may be a significant contributor to the increased prevalence of headaches in military veterans. Concussions, usually due to blast exposure, occur in approximately 20% of deployed SMs, and headaches are a common symptom after a deployment-related concussion. Posttraumatic headaches (PTHAs) in US SMs usually resemble migraines, and posttraumatic stress disorder (PTSD) and depression are common comorbidities. Treatment of PTHAs in SMs is based upon the treatment setting, whether the headaches are acute or chronic, the headache phenotype, and associated comorbidities. No randomized, controlled clinical trials evaluating the efficacy of therapies for PTHAs have been completed. Pharmacologic and nonpharmacologic management strategies should be selected on an individual basis. Acute therapy with NSAIDs or triptans and prophylactic therapy in acute and chronic settings using valproate, nortriptyline, amitriptyline, propranolol, topiramate, or botulinum toxin are discussed. Triptans and topiramate may be particularly effective in SMs with PTHA. Management of PTHA and other features of the posttraumatic syndrome should be multidisciplinary whenever possible.

Headaches during war: Analysis of presentation, treatment, and factors associated with outcome

Background: Headache is often associated with physical trauma and psychological stress. The aim of this study is to evaluate the impact of headache on personnel deployed in war zones and to identify factors associated with return to duty (RTD).

Methods: Outcome data were prospectively collected on 985 personnel medically evacuated out of Operations Iraqi and Enduring Freedom for a primary diagnosis of headache between 2004 and 2009. Electronic medical records were reviewed to examine clinical and treatment patterns and the effect that myriad factors had on RTD.

Results: 33.6% of evacuees returned to duty. The most common headaches were post-concussion (34.1%) and migraine (30.0%). Headaches typically associated with trauma such as post-concussion (18.7%), occipital neuralgia (23.1%), and cervicogenic headache (29.7%) had the lowest RTD rates, whereas tension headache (49.6%) was associated with the best outcome. Other variables associated with negative outcome included presence of aura (OR 0.51, 95% CI 0.30–0.88; p = 0.02), traumatic brain injury (OR 0.50, 95% CI 0.29–0.87; p = 0.01), opioid (OR 0.41, 95% CI 0.26–0.63; p < 0.001), and beta-blocker (OR 0.26, 95% CI 0.12–0.61; p = 0.002) use, and co-existing psychopathology ( p < 0.001 in univariable analysis).

Conclusion: Headaches represent a significant cause of unit attrition in personnel deployed in military operations, with physical trauma and co-existing psychopathology associated with poorer outcomes.

Blocking the greater occipital nerve: utility in headache management

Occipital nerve block has been part of headache medicine for more than half a century, with injection techniques and solutions varying greatly. Most studies have been case series and many show benefit for patients with migraine, cluster headache, and postconcussive headache. A double-blind, controlled trial of cluster headache has demonstrated that injectable steroids with local anesthetics benefit cluster headache patients. A double-blind, controlled trial of nerve blocks in occipital neuralgia, which may have actually been chronic migraine, was positive.

Anatomical study of the third occipital nerve and its potential role in occipital headache/neck pain following midline dissections of the craniocervical junction

OBJECTIVE

Occipital neuralgia can be a debilitating disease and may occur following operative procedures near the occipital and nuchal regions. One nerve of this region, the third occipital nerve (TON), has received only scant attention, and its potential contribution to occipital neuralgia has not been appreciated. Therefore, in the present study the authors aimed to detail the anatomy of this nerve and its relationships to midline surgical approaches of the occiput and posterior neck.

METHODS

Fifteen adult cadavers (30 sides) underwent dissection of the upper cervical and occipital regions. Special attention was given to identifying the course of the TON and its relationship to the soft tissues and other nerves of this region. Once identified superficially, the TON was followed deeply through the nuchal musculature to its origin in the dorsal ramus of C-3. Measurements were made of the length and diameter of the TON. Additionally, the distance from the external occipital protuberance was measured in each specimen. Following dissection of the TON, self-retaining retractors were placed in the midline and opened in standard fashion while observing for excess tension on the TON.

RESULTS

Articular branches were noted arising from the deep surface of the nerve in 63.3% of sides. The authors found that the TON was, on average, 3 mm lateral to the external occipital protuberance, and small branches were found to cross the midline and communicate with the contralateral TON inferior to the external occipital protuberance in 66.7% of sides. The TON trunk became subcutaneous at a mean of 5 cm inferior to the external occipital protuberance. In all specimens, the cutaneous main trunk of the TON was intimately related to the nuchal ligament. Insertion of self-retaining retractors in the midline placed significant tension on the TON in all specimens, both superficially and more deeply at its adjacent facet joint.

CONCLUSIONS

Although damage to the TON may often be unavoidable in midline approaches to the craniocervical region, appreciation of its presence and knowledge of its position and relationships may be useful to the neurosurgeon who operates in this region and may assist in decreasing postoperative morbidity.

Nerve blocks in the treatment of headache

Nerve blocks and neurostimulation are reasonable therapeutic options in patients with head and neck neuralgias. In addition, these peripheral nerve procedures can also be effective in primary headache disorders, such as migraine and cluster headaches. Nerve blocks for headaches are generally accomplished by using small subcutaneous injections of amide-type local anesthetics, such as lidocaine and bupivicaine. Targets include the greater occipital nerve, lesser occipital nerve, auriculotemporal nerve, supratrochlear and supraorbital nerves, sphenopalatine ganglion, cervical spinal roots, and facet joints of the upper cervical spine. Although definitive studies examining the usefulness of nerve blocks are lacking, reports suggest that this area deserves further attention in the hope of acquiring evidence of effectiveness.

Do pediatric headaches respond to bilateral lower cervical paraspinous bupivacaine injections?

OBJECTIVE

Bilateral lower cervical paraspinous intramuscular bupivacaine injections have recently been reported as a therapeutic modality for headache pain in adult patients presenting to an emergency department. In this study, we accomplished a retrospective review of all pediatric patients with headaches who were treated with this technique in an emergency department setting over a 16-month period. The therapeutic response of all pediatric patients who received bilateral lower cervical paraspinous intramuscular bupivacaine injections for headache pain is described in this article.

METHODS

Three separate databases were reviewed to capture all patients younger than 18 years with a diagnosis of headache who received bilateral cervical injections between June 30, 2003, and December 1, 2004, in the Medical College of Georgia and Children's Medical Center emergency departments. Their medical records were retrospectively reviewed to determine their response to this procedure.

RESULTS

The headaches of 13 patients younger than 18 years were treated with this procedure. The mean headache severity was 9.15, and the mean duration of headache was 3.16 days. Six (46.2%) of 13 patients had complete relief of their headaches, whereas 5 (38.4%) of 13 patients had partial relief. No significant relief was documented in 2 (15.4%) of 13 patients. A therapeutic response was documented in 11 (84.6%) of 13 of the patients.

CONCLUSIONS

These retrospective observations suggest that bilateral lower cervical paraspinous intramuscular injections with small amounts of bupivacaine may have a therapeutic role in the management of headache pain in children, and their rate of therapeutic response may be similar to that recently reported for adult headache patients.