Role of greater occipital nerve blocks and trigger point injections for patients with dizziness and headache

Intermediate Cervical Plexus Block in the Management of Refractory Somatosensory Tinnitus Following Whiplash: Prospective Series in 30 Patients

OBJECTIVE

Whiplash-associated disorder comprises of a constellation of persistent symptoms after neck trauma. Tinnitus that develops postwhiplash is termed somatosensory tinnitus. The objective is to assess the role of intermediate cervical plexus block (iCPB) in patients with somatosensory tinnitus secondary to whiplash.

METHODS

Prospective service evaluation in adults with whiplash-associated disorder and concomitant somatosensory tinnitus. Patients underwent specialist otorhinolaryngology review before pain clinic referral. Patients were offered ultrasound-guided iCPB with steroids. Intensity of tinnitus was recorded on a numerical rating scale at baseline, 3 and 6 months posttreatment. Brief Pain Inventory Short Form and Hospital Anxiety Depression Scale questionnaires were also completed.

RESULTS

Over a 36-month period, 32 patients with refractory somatosensory tinnitus following whiplash were offered iCPB(s). Two patients refused because of needle phobia. iCPB(s) was performed in 30 patients as an outpatient procedure. One patient (1/30, 3.3%) was lost to follow-up. Twenty-three patients (23/30, 77%) reported clinically significant reduction in intensity of tinnitus at 3 months postprocedure. Nineteen patients (19/30, 63%) reported ongoing benefit at 6-month follow-up. Six patients failed to report any benefit (6/30, 20%).

CONCLUSION

The cervical plexus could play a significant role in the development of somatosensory tinnitus after whiplash. iCPB may have a role in the management of somatosensory tinnitus in this cohort.

A Pilot Analysis on the Efficacy of Multiple Trigger-Point Saline Injections in Chronic Tension-Type Headache: A Retrospective Observational Study

This study aimed to investigate the efficacy of new targeted trigger-point injections (TPIs) using isotonic saline in patients with chronic tension-type headache (CTTH). Of 121 patients with headache who were retrospectively reviewed, 19 were included in this study and were categorized into two groups: those who received TPIs more than four times (group 1); and those who received TPIs less than, or equal to, four times (group 2). The patients received ultrasound-guided isotonic saline injections into the active trigger points once weekly. The primary outcome was an effect on headache intensity, determined using the visual analog scale (VAS), whereas the secondary outcome was an effect on quality of life, evaluated using the Henry Ford Hospital Headache Disability Inventory (HDI). The mean symptom duration of the 19 patients (11 men and 8 women; mean age, 52.5 years; and range, 23−81 years) was 16 months. The most frequently injected muscle was the splenius capitis. Patient demographics were similar between the two groups (p > 0.05). Simple linear regression revealed that symptom duration (p = 0.001) and baseline VAS score (p = 0.009) were significantly associated with the number of injections. At one month after the first injection, the mean VAS and HDI scores in group 2 were significantly lower than those in group 1 (p < 0.05), whereas the scores significantly decreased immediately after the last injection in both groups (p < 0.05). No adverse effects were reported in any patient. Our results indicate that the administration of new targeted TPIs using isotonic saline into the head and neck muscles of patients with CTTH can effectively relieve headache intensity and safely improve their quality of life.

Anatomy of the greater occipital nerve: implications in posterior fossa approaches

PURPOSE

Because of its superficial location in the dorsal regions of the scalp, the greater occipital nerve (GON) can be injured during neurosurgical procedures, resulting in post-operative pain and postural disturbances. The aim of this work is to specify the course of the GON and how its injuries can be avoided while performing posterior fossa approaches.

METHODS

This study was carried out at the department of anatomy at Bordeaux University. 4 specimens were dissected to study the GON course. Posterior fossa approaches (midline suboccipital, paramedian suboccipital, retrosigmoid and petrosal) were performed on 4 other specimens to assess potential risks of GON injuries.

RESULTS

The GON runs around the obliquus capitis inferior (100%), crosses the semispinalis capitis (100%) and the trapezius (75%) or its aponeurosis (25%). Direct GON injuries can be seen in paramedian suboccipital approaches. Stretching of the GON can occur in midline suboccipital and paramedian suboccipital approaches. We found no evidence of direct or indirect GON injury in retrosigmoid or petrosal approaches.

CONCLUSION

Our study provides interesting data regarding the risk GON injury in posterior fossa approaches. Direct GON injuries in paramedian suboccipital approaches can be avoided with careful dissection. Placing retractors in contact with the periosteum and performing a minimal retraction may help to avoid excessive GON stretching in midline suboccipital and paramedian suboccipital approaches. Furthermore, the incision for retrosigmoid approaches should be as lateral as possible and not too caudal. Finally, avoiding extreme patient positioning reduces the risk of GON stretching in all approaches.

Care Gaps and Recommendations in Vestibular Migraine: An Expert Panel Summit

Vestibular migraine (VM) is an increasingly recognized pathology yet remains as an underdiagnosed cause of vestibular disorders. While current diagnostic criteria are codified in the 2012 Barany Society document and included in the third edition of the international classification of headache disorders, the pathophysiology of this disorder is still elusive. The Association for Migraine Disorders hosted a multidisciplinary, international expert workshop in October 2020 and identified seven current care gaps that the scientific community needs to resolve, including a better understanding of the range of symptoms and phenotypes of VM, the lack of a diagnostic marker, a better understanding of pathophysiologic mechanisms, as well as the lack of clear recommendations for interventions (nonpharmacologic and pharmacologic) and finally, the need for specific outcome measures that will guide clinicians as well as research into the efficacy of interventions. The expert group issued several recommendations to address those areas including establishing a global VM registry, creating an improved diagnostic algorithm using available vestibular tests as well as others that are in development, conducting appropriate trials of high quality to validate current clinically available treatment and fostering collaborative efforts to elucidate the pathophysiologic mechanisms underlying VM, specifically the role of the trigemino-vascular pathways.

The Bárány Society position on 'Cervical Dizziness'

This paper describes the Bárány Society Classification OverSight Committee (COSC) position on Cervical Dizziness, sometimes referred to as Cervical Vertigo. This involved an initial review by a group of experts across a broad range of fields, and then subsequent review by the Bárány Society COSC. Based upon the so far published literature, the Bárány Society COSC takes the view that the evidence supporting a mechanistic link between an illusory sensation of self-motion (i.e. vertigo - spinning or otherwise) and neck pathology and/or symptoms of neck pain - either by affecting the cervical vertebrae, soft tissue structures or cervical nerve roots - is lacking. When a combined head and neck movement triggers an illusory sensation of spinning, there is either an underlying common vestibular condition such as migraine or BPPV or less commonly a central vestibular condition including, when acute in onset, dangerous conditions (e.g. a dissection of the vertebral artery with posterior circulation stroke and, exceedingly rarely, a vertebral artery compression syndrome). The Committee notes, that migraine, including vestibular migraine, is by far, the commonest cause for the combination of neck pain and vestibular symptoms. The committee also notes that since head movement aggravates symptoms in almost any vestibular condition, the common finding of increased neck muscle tension in vestibular patients, may be linked as both cause and effect, to reduced head movements. Additionally, there are theoretical mechanisms, which have not been explored, whereby cervical pain may promote vaso-vagal, cardio-inhibitory reflexes and hence by presyncopal mechanisms, elicit   transient   disorientation and/or imbalance. The committee accepts that further research is required to answer the question as to whether those rare cases in which neck muscle spasm is associated with a vague sense of spatial disorientation and/or imbalance, is indeed linked to impaired neck proprioception. Future studies should ideally be placebo controlled and double-blinded where possible, with strict inclusion and exclusion criteria that aim for high specificity at the cost of sensitivity. To facilitate further studies in "cervical dizziness/vertigo", we provide a narrative view of the important confounds investigators should consider when designing controlled mechanistic and therapeutic studies. Hence, currently, the Bárány COSC refrains from proposing any preliminary diagnostic criteria for clinical use outside a research study. This position may change as new research evidence is provided.

Cervicogenic dizziness alleviation after coblation discoplasty: a retrospective study

OBJECTIVE

Little is known about the therapeutic relationship between coblation discoplasty and cervicogenic dizziness (CGD). CGD can be caused by abnormal proprioceptive inputs from compressed nerve roots, intradiscal mechanoreceptors and nociceptors to the vestibulospinal nucleus in the degenerative cervical disc. The aim was to analyze the efficacy of coblation discoplasty in CGD through intradiscal nerve ablation and disc decompression in a 12-month follow-up retrospective study.

METHODS

From 2015 to 2019, 42 CGD patients who received coblation discolplasty were recruited as the surgery group, and 22 CGD patients who rejected surgery were recruited as the conservative group. Using intent-to-treat (ITT) analysis, we retrospectively analyzed the CGD visual analogue scale (VAS), neck pain VAS, CGD frequency score, and the CGD alleviation rating throughout a 12-month follow-up period.

RESULTS

Compared with conservative intervention, coblation discoplasty revealed a better recovery trend with effect sizes of 1.76, 2.15, 0.92, 0.78 and 0.81 in CGD VAS, and effect sizes of 1.32, 1.54, 0.93, 0.86 and 0.76in neck pain VAS at post-operative 1 week, and 1, 3, 6, 12 months, respectively. The lower CGD frequency score indicated fewer attacks of dizziness until postoperative 3 months (p < 0.01). At post-operative 12 months, the coblation procedure showed increased satisfactory outcomes of CGD alleviation rating (p < .001, -1.00 of effect size).

CONCLUSIONS

Coblation discoplasty significantly improves the severity and frequency of CGD, which is important inbridging unresponsive conservative intervention and open surgery.Key messagesThere is a correlation between the degenerative cervical disc and cervicogenic dizziness (CGD).CGD can be caused by abnormal proprioceptive inputs from a compressed nerve root and intradiscal mechanoreceptors and nociceptors to the vestibulospinal nucleus in the degenerative cervical disc.Cervical coblation discoplasty can alleviate CGD through ablating intradiscal nerve endings and decompressing the nerve root.

Increased mechanosensivity of the greater occipital nerve in subjects with side-dominant head and neck pain - a diagnostic case-control study

Objectives: To investigate differences in pressure pain thresholds (PPTs) and longitudinal mechanosensitivity of the greater occipital nerve (GON) between patients with side-dominant head and neck pain (SDHNP) and healthy controls. Evaluation of neural sensitivity is not a standard procedure in the physical examination of headache patients but may influence treatment decisions. Methods: Two blinded investigators evaluated PPTs on two different locations bilaterally over the GON as well as the occipitalis longsitting-slump (OLSS) in subjects with SDHNP (n = 38)) and healthy controls (n = 38). Results: Pressure pain sensitivity of the GON was lower at the occiput in patients compared to controls (p = 0.001). Differences in pressure sensitivity of the GON at the nucheal line, or between the dominant headache side and the non-dominant side were not found (p > 0.05). The OLSS showed significant higher pain intensity in SDHNP (p < 0.001). In comparison to the non-dominant side, the dominant side was significantly more sensitive (p = 0.004). Discussion: Palpation of the GON at the occiput and the OLSS may be potentially relevant tests in SDHNP. One explanation for an increased bilateral sensitivity may be sensitization mechanisms. Future research should investigate the efficacy of neurodynamic techniques directed at the GON. Level of Evidence: 3b.

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.

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.

Spinal rehabilitative exercise or manual treatment for the prevention of cervicogenic headache in adults

This is the protocol for a review and there is no abstract. The objectives are as follows: To quantify and compare the short- and long-term effects of manual treatment and spinal rehabilitative exercise for cervicogenic headache, classified according to the International Headache Society's (IHS) diagnostic criteria, with an active or placebo/sham comparison or wait-list control.

Perspectives in ultrasound-guided musculoskeletal interventions

Ultrasonography (USG) is a safe, easily available, and cost-effective modality, which has the additional advantage of being real time for imaging and image-guided interventions of the musculoskeletal system. Musculoskeletal interventions are gaining popularity in sports and rehabilitation for rapid healing of muscle and tendon injuries in professional athletes, healing of chronic tendinopathies, aspiration of joint effusions, periarticular bursae and ganglia, and perineural injections in acute and chronic pain syndromes. This article aims to provide an overview of the spectrum of musculoskeletal interventions that can be done under USG guidance both for diagnostic and therapeutic purposes.

Cervical epidural steroid injection for refractory somatic tinnitus

Somatic tinnitus is a common disorder, yet few treatments described in the literature have demonstrated strong efficacy. We report a case of a 61-year-old male with refractory somatic tinnitus, temporally related to a prior bacterial otitis media, wherein auditory symptoms were successfully treated with cervical epidural injections of long-acting corticosteroid. We discuss the proposed mechanism of somatic tinnitus and the means by which neuraxial steroids may inhibit somatic tinnitus symptoms.

Trigger point injections for headache disorders: expert consensus methodology and narrative review

OBJECTIVE/BACKGROUND

To review the existing literature and describe a standardized methodology by expert consensus for the performance of trigger point injections (TPIs) in the treatment of headache disorders. Despite their widespread use, the efficacy, safety, and methodology of TPIs have not been reviewed specifically for headache disorders by expert consensus.

METHODS

The Peripheral Nerve Blocks and Other Interventional Procedures Special Interest Section of the American Headache Society over a series of meetings reached a consensus for nomenclature, indications, contraindications, precautions, procedural details, outcomes, and adverse effects for the use of TPIs for headache disorders. A subcommittee of the Section also reviewed the literature.

RESULTS

Indications for TPIs may include many types of episodic and chronic primary and secondary headache disorders, with the presence of active trigger points (TPs) on physical examination. Contraindications may include infection, a local open skull defect, or an anesthetic allergy, and precautions are necessary in the setting of anticoagulant use, pregnancy, and obesity with unclear anatomical landmarks. The most common muscles selected for TPIs include the trapezius, sternocleidomastoid, and temporalis, with bupivacaine and lidocaine the agents used most frequently. Adverse effects are typically mild with careful patient and procedural selection, though pneumothorax and other serious adverse events have been infrequently reported.

CONCLUSIONS

When performed in the appropriate setting and with the proper expertise, TPIs seem to have a role in the adjunctive treatment of the most common headache disorders. We hope our effort to characterize the methodology of TPIs by expert opinion in the context of published data motivates the performance of evidence-based and standardized treatment protocols.

Therapeutic options for cervicogenic headache

The term cervicogenic headache (CeH) describes a syndrome originating from the cervical spine. There are a variety of therapeutic approaches used for the management of CeH, but scientific evidence of their effectiveness is scarce. No medication drug has proven to be effective. The evidence for greater occipital nerve blocks, cervical nerve blockades, facet joint injections and surgical procedures is limited. Several physical therapy interventions are proposed for CeH, with spinal manipulation and soft tissue interventions being the most commonly used. However, the lack of solid evidence of positive effects and risks of serious complications for spinal manipulation should be considered in favor of other physical therapy interventions associated with less risk. The inconsistent results in the literature can be related to the fact that maybe not all therapeutic interventions are appropriate for all patients with CeH or maybe not all patients with CeH will benefit from particular interventions.

Vertigo as a migraine phenomenon

Migraine is a complex disorder with many different manifestations. There has been an increasing interest in the association of migraine and vertigo. Many different terms have been developed to describe this concept, the more popular being vestibular migraine, migrainous vertigo, and migraine-associated vertigo. The most commonly cited diagnostic criteria are that of Neuhauser though this has yet to be included in the International Classification of Headache Disorders (2nd edition). At this time, there is a lack of consensus regarding migraine-related vertigo and its pathomechanism. Regardless, a few randomized controlled prospective studies have been performed to evaluate the efficacy of various medications. Topiramate has been shown to be effective for migraine-related vertigo. At this time there is no specific treatment for migraine-related dizziness outside of conventional migraine management. The genetics have yet to be fully realized though an autosomal dominant familial migraine vertigo disorder has been identified.

Chronic daily headache in children and adolescents: science and conjecture

SUMMARY Chronic daily headache comprises a group of headache disorders in which headaches occur almost daily or continuously over several months. Although chronic daily headache is one of the most common chronic pain disorders in pediatrics, data on pathophysiological mechanisms and relative efficacy of treatments remain sparse. In this review, we aim to provide contemporary information on classification, epidemiology, etiology and treatment of pediatric chronic daily headache based on extant empirical data when available, or general consensus in the field when not.