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

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.

Sequential administration of peripheral nerve blocks and onabotulinumtoxinA for the treatment of chronic migraine and other headache disorders-A retrospective tolerability and safety study

OBJECTIVE

To determine the tolerability and safety of concurrent peripheral nerve blocks and onabotulinumtoxinA treatment during a single outpatient clinic procedure visit.

BACKGROUND

Procedural interventions are available for the treatment of headache disorders. OnabotulinumtoxinA and peripheral nerve blocks are used as alternatives or in addition to oral therapies to reduce the frequency and intensity of migraine attacks. There is currently a lack of safety data focusing on the sequential administration of local anesthetic via peripheral nerve blocks and onabotulinumtoxinA during a single clinical encounter for the treatment of headache. The primary aim of the study was to determine the safety and tolerability of concurrent peripheral nerve blockade and onabotulinumtoxinA injections during a single outpatient clinic procedure visit. We hypothesized that the dual intervention would be safe and well tolerated by patients with chronic migraine and other headache disorders.

METHODS

A retrospective chart review was performed using clinical data from patients seen by multiple providers over a 16-month timeframe at one outpatient headache clinic. Patients were identified by procedure codes and those receiving peripheral nerve block(s) and onabotulinumtoxinA injections during a single encounter within the study period were eligible for inclusion. Inclusion criteria were (1) patients 18 years and older who were (2) receiving both peripheral nerve blocks and onabotulinumtoxinA injections for the treatment of chronic migraine. Patients were excluded if they were under age 18, received their procedure outside of the clinic (emergency room, inpatient ward), or were receiving sphenopalatine ganglion blocks. Age- and sex-matched patients who received one procedure, either peripheral nerve blocks or onabotulinumtoxinA, were used for control. The primary outcome of this safety study was the number of adverse events that occurred in the dual intervention group compared to the single intervention control arms. Information regarding adverse events was gathered via retrospective chart review. If an adverse event was recorded, it was then graded by the reviewer utilizing the Common Terminology Criteria for Adverse Events ranging from Grade 1 Mild Event to Grade 5 Death. Additionally, it was noted whether the adverse event led to treatment discontinuation.

RESULTS

In total, 375 patients were considered eligible for inclusion in the study. After age and sex matching of controls, 131 patients receiving dual intervention were able to be compared to 131 patients receiving onabotulinumtoxinA alone and 104 patients receiving dual intervention were able to be compared to 104 patients receiving peripheral nerve block(s) alone. The primary endpoint analysis showed no significant difference in total adverse events between dual intervention compared to nerve blocks alone or onabotulinumtoxinA alone. The number of adverse events that led to treatment discontinuation approached but did not reach statistical significance for those receiving dual intervention versus onabotulinumtoxinA alone in the number of adverse events that led to treatment termination (4.6%, 6/131 vs. 0.8%, 1/131, p = 0.065); however, the number of patients who discontinued therapy was not significantly different between those groups (2.3%, 3/131 vs. 0.8%, 1/131; p = 0.314; odds ratio 0.3 [0-3.2]; p = 0.338).

CONCLUSIONS

In this retrospective chart review, there was no significant difference in adverse events or therapy discontinuation between patients receiving sequential peripheral nerve block(s) and onabotulinumtoxinA injections versus those receiving either peripheral nerve block(s) or onabotulinumtoxinA injections alone. As a result, we concluded that the combination procedure is likely safe and well tolerated in routine clinical practice.

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.

Approach to the Patient With Headache

OBJECTIVE

The evaluation of patients with headache relies heavily on the history. This article reviews key questions for diagnosing primary and secondary headache disorders with a rationale for each and phrasing to optimize the information obtained and the patient's experience.

LATEST DEVELOPMENTS

The availability of online resources for clinicians and patients continues to increase, including sites that use artificial intelligence to generate a diagnosis and report based on patient responses online. Patient-friendly headache apps include calendars that help track treatment response, identify triggers, and provide educational information.

ESSENTIAL POINTS

A structured approach to taking the history, incorporating online resources and other technologies when needed, facilitates making an accurate diagnosis and often eliminates the need for unnecessary testing. A detailed yet empathetic approach incorporating interpersonal skills enhances relationship building and trust, both of which are integral to successful treatment.

Headache in Children and Adolescents

OBJECTIVE

This article reviews the assessment of children and adolescents presenting with headache, provides an overview of primary headache disorders, and reviews evidence-based management of headache in this age group.

LATEST DEVELOPMENTS

In the last few years, new epidemiological data have shed light on less common pediatric headache disorders (eg, pediatric trigeminal autonomic cephalalgias) and psychosocial risk factors associated with primary headache disorders in children and adolescents. There has also recently been a substantial increase in interventions that target the calcitonin gene-related peptide pathway and that treat primary headache disorders using noninvasive neuromodulation. Although these interventions have primarily been studied in adults, there is emerging evidence of their use in the pediatric population.

ESSENTIAL POINTS

Primary headache disorders are very common in youth, and the most commonly encountered headache diagnosis in neurology practice is migraine, which affects approximately 10% of children and adolescents. Diagnosing and effectively treating primary headache disorders before adulthood may have a sustained impact on the patient by improving long-term headache and mental health outcomes, thereby significantly reducing the burden of disability over time. There are several available and emerging acute and preventive interventions for youth with primary headache disorders, and treatment decisions should be made in the context of available evidence using a shared decision-making approach.

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.

Relative Pain Reduction and Duration of Nerve Block Response Predict Outcomes in Headache Surgery: A Prospective Cohort Study

BACKGROUND

Experts agree that nerve block (NB) response is an important tool in headache surgery screening. However, the predictive value of NBs remains to be proven in a prospective fashion.

METHODS

Pre-NB and post-NB visual analogue pain scores (0 to 10) and duration of NB response were recorded prospectively. Surgical outcomes were recorded prospectively by calculating the Migraine Headache Index (MHI) preoperatively and postoperatively at 3 months, 12 months, and every year thereafter.

RESULTS

The study population included 115 patients. The chance of achieving MHI percentage improvement of 80% or higher was significantly higher in subjects who reported relative pain reduction of greater than 60% following NB versus less than or equal to 60% [63 of 92 (68.5%) versus 10 of 23 (43.5%); P = 0.03]. Patients were more likely to improve their MHI 50% or more with relative pain reduction of greater than 40% versus 40% or less [82 of 104 (78.8%) versus five of 11 (45.5%); P = 0.01]. In subjects with NB response of greater than 15 days, 10 of 13 patients (77.0%) experienced MHI improvement of 80% or greater. Notably, all of these patients (100%) reported MHI improvement of 50% or greater, with mean MHI improvement of 88%. Subjects with a NB response of 24 hours or more achieved significantly better outcomes than patients with a shorter response (72.7% ± 37.0% versus 46.1% ± 39.7%; P = 0.02). However, of 14 patients reporting NB response of less than 24 hours, four patients had MHI improvement of 80% or greater, and seven, of 50% or greater.

CONCLUSIONS

Relative pain reduction and duration of NB response are predictors of MHI improvement after headache surgery. NBs are a valuable tool to identify patients who will benefit from surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

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.

Occipital Nerve Block Compared With Acetaminophen and Caffeine for Headache Treatment in Pregnancy: A Randomized Controlled Trial

OBJECTIVE

To evaluate the efficacy of occipital nerve block compared with standard care , defined as acetaminophen with caffeine, for treatment of acute headache in pregnancy.

METHODS

We conducted a single-center, unblinded, parallel, randomized controlled trial of pregnant patients with headache and pain score higher than 3 on the visual rating scale. Patients with secondary headache, preeclampsia, or allergy or contraindication to study medications were excluded. Participants were randomized to occipital nerve block or standard care (oral 650 mg acetaminophen and 200 mg caffeine). Crossover treatment was given at 2 hours and second-line treatment at 4 hours to those with worsening visual rating scale score or visual rating scale score higher than 3. The primary outcome was headache improvement to a visual rating scale score of 3 or lower within 2 hours of initial therapy. Secondary outcomes included serial visual rating scale scores, receipt of crossover or second-line therapy, patient satisfaction, and perinatal outcomes. Outcomes were assessed in an intention-to-treat analysis. We estimated that a sample of 62 would provide 80% power to detect a difference from 85% to 50% between groups.

RESULTS

From February 2020 to May 2022, 62 participants were randomized to occipital nerve block (n=31) or standard care (n=31). Groups were similar except payer status. The primary outcome, headache improvement to visual rating scale score of 3 or lower, was not significantly different between groups (64.5% vs 51.6%, P =.30). The occipital nerve block group experienced lower median [interquartile range] visual rating scale scores at 1 hour (2 [0-5] vs 6 [2-7], P =.014), and more patients in the occipital nerve block group had visual rating scale scores of 3 or lower at 1 hour. Among patients receiving crossover treatment at 2 hours, the standard care group had a significantly lower visual rating scale score 1 hour after crossover to occipital nerve block than the occipital nerve block group receiving crossover to standard care ( P =.028). There were no significant differences in second-line treatment, refractory headache, satisfaction, or complications. Patients receiving occipital nerve block delivered earlier (36.6 weeks vs 37.8 weeks), but preterm birth did not differ between groups.

CONCLUSION

Occipital nerve block is an effective and quick-acting treatment option for acute headache in pregnancy.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT03951649.

Pharmacological Management of Orofacial Pain

Orofacial pain is a category of complex disorders, including musculoskeletal, neuropathic and neurovascular disorders, that greatly affect the quality of life of the patient. These disorders are within the fields of dentistry and medicine and management can be challenging, requiring a referral to an orofacial pain specialist, essential for adequate evaluation, diagnosis, and care. Management is specific to the diagnosis and a treatment plan is developed with diverse pharmacological and non-pharmacological modalities. The pharmacological management of orofacial pain encompasses a vast array of medication classes and approaches. This includes anti-inflammatory drugs, muscle relaxants, anticonvulsants, antidepressants, and anesthetics. In addition, as adjunct therapy, different injections can be integrated into the management plan depending on the diagnosis and needs. These include trigger point injections, temporomandibular joint (TMJ) injections, and neurotoxin injections with botulinum toxin and nerve blocks. Multidisciplinary management is key for optimal care. New and safer therapeutic targets exclusively for the management of orofacial pain disorders are needed to offer better care for this patient population.

The effects of greater occipital nerve blockage with lidocaine on sleep characteristics in chronic migraine patients

PURPOSE

The aim of our study was to determine the effects of greater occipital nerve block (GONB) with lidocaine on sleep characteristics in patients with chronic migraine.

MATERIALS AND METHODS

Twenty female patients who underwent GONB with lidocaine were included in the study. The Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), Insomnia Severity Index (ISI), Pre-Sleep Arousal Scale (PSAS), Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS), Restless Legs Syndrome Severity Scale (RLSSS), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and headache diary results before and after the treatment of the patients were compared.

RESULTS

We included 20 patients (all females) in our study. The mean age was 35.80 ± 8.82 years (range 24-50). After GON blockade, the number of days with pain (p < 0.001), duration of pain (p < 0.001), and Visual Analog Scale (VAS) score (p < 0.001) were significantly lower than before. After GONB, BDI (p = 0.007), BAI (p = 0.022), ISI (p = 0.009), and PSQI (p = 0.026) scores were significantly lower than before. After GONB, sleep quality was better than before (p = 0.035).

CONCLUSION

This study showed that GONB with lidocaine can improve sleep quality, insomnia, and symptoms of depression and anxiety while reducing migraine headache.

Greater occipital nerve block in the treatment of headaches. Review of evidence

INTRODUCTION

Peripheral nerve blocks have been a common treatment for multiple headaches. By far, the greater occipital nerve block is the most used and with the stronger body of evidence in routine clinical practice.

METHODS

We searched Pubmed Meta-Analysis/Systematic Review, in the last 10 years. Of these results, meta-analyses, and in the absence of these systematic reviews, assessing Greater Occipital Nerve Block in headache has been selected for review.

RESULTS

We identified 95 studies in Pubmed, 13 that met the inclusion criteria.

CONCLUSION

Greater occipital block is an effective and safe technique, easy to perform and which has shown its usefulness in migraine, cluster headache, cervicogenic headache and Post-dural puncture headache. However, more studies are needed to clarify its long-term efficacy, its place in clinical treatment, the possible difference between different anaesthetics, the most convenient dosage and the role of concomitant use of corticosteroids.

Review of Interventional Therapies for Refractory Pediatric Migraine

This is a review of the latest and seminal evidence in pediatric migraine. It covers the etiology and pathophysiology known today, and then will review treatment options, efficacy and safety, quality of data and indications. Though migraine is usually regarded as an infliction in adults, it is not uncommon in the pediatric population and affects up to 8% of children. Children may experience migraine differently than adults, and present not only with headache but also frequent gastrointestinal symptoms. They are frequently shorter in duration than in adults. Traditional migraine treatment in adults is less effective in children. In this population, adjunct therapies - such as interventional techniques - should be considered when traditional treatment fails, including Botulinum Toxin A (BTA) injections, peripheral nerve and ganglion blocks. BTA injections are FDA approved for migraine prophylaxis in adults, but currently not in children; however, recent evidence shows efficacy and safety in pediatric migraine management. Nerve blocks stop nociceptive afferent fibers through injection of local anesthetics, and it may be associated with the local injection of corticosteroids. Although more common in adults, recent data suggests they are safe and effective in children and adolescents. Blocking the sphenopalatine ganglion can be achieved through nasal approach, and achieves a similar action by blocking the entire ganglion. Interventional techniques may provide a key component in the alleviation of this otherwise debilitating chronic migraine pain. Though most studies have been performed in adults, new studies provide encouraging results for treatment in children.

Greater Occipital Nerve Block as an Effective Intervention for Medically Refractory Pediatric Migraine: A Retrospective Study

Background Migraine is a common complaint worldwide, spanning all ages, but is not so well investigated in children and adolescents. Pediatric migraines incur significant health and social consequences with the most incisive effects seen in school performance, physical health, and mental well-being, making early effective management of pediatric migraine desirable. However, unlike adult migraine, the treatment for pediatric migraine has not been well established, which is especially true for the treatment of medically refractory migraine in children. Methodology We conducted a retrospective study to assess the feasibility of greater occipital nerve (GON) blocks as a therapeutic option for medically refractory migraine in children. We recruited subjects under 18 years old with a severe medically refractory headache that was affecting day-to-day life and who consented to receive a GON block. GON block effectivity was assessed through follow-up consultations and a post-procedural questionnaire. Results Six subjects received a first-time GON block for medically refractory migraine (mean age = 12 years and three months old, age range = 10 to 15 years old, three out of six subjects were female). We found that GON block was effective in all six patients for treatment of medically refractory migraine as assessed through follow-up consultations and a questionnaire sent out six weeks post-intervention. GON block was generally tolerable with only one patient reporting side effects (migraine flare-up for three days) post-intervention. Repeat injection was performed in four out of six patients, all of whom reported a repeat benefit. Conclusions We conclude that GON block is a feasible therapeutic option for the management of medically refractory migraine in children.

Greater occipital nerve blockade for the preventive treatment of chronic migraine: A randomized double-blind placebo-controlled study

BACKGROUND

Greater occipital nerve blockade for the prevention of chronic migraine has a limited evidence base. A robust randomized double-blind, placebo-controlled trial is needed.

METHODS

This double-blind, placebo-controlled, parallel-group trial, following a baseline period of four weeks, randomly assigned patients of chronic migraine 1:1 to receive four-weekly bilateral greater occipital nerve blockade with either 2 ml of 2% (40 mg) lidocaine (active group) or 2 ml of 0.9% saline (placebo) injections for 12 weeks. The primary and key secondary efficacy endpoints were a change from the baseline in the mean number of headache and migraine days and the achievement of ≥50% reduction in headache days from baseline across the weeks 9-12 respectively. Safety evaluations included the documentation and reporting of serious and other adverse events.

RESULTS

Twenty-two patients each were randomly allocated to the active and placebo group. Baseline demography and clinical characteristics were similar between the two groups. Mean headache and migraine days at baseline (±SD) were 23.4 ± 4.4 and 15.6 ± 5.7 days in the active group and 22.6 ± 5.0 and 14.6 ± 4.6 days in the placebo group respectively. The active group compared to the placebo had a significantly greater least-squares mean reduction in the number of headache and migraine days (-4.2 days [95% CI: -7.5 to -0.8; p  =  0.018] and -4.7 days [95%CI: -7.7 to -1.7; p = 0.003] respectively). 40.9% of patients in the active group achieved ≥50% reduction in headache days as compared with 9.1% of patients receiving a placebo (p = 0.024). Overall, 64 mild and transient adverse events were reported by 16 patients in the active group and 15 in the placebo. No death or serious adverse events were reported.

CONCLUSION

Four-weekly greater occipital nerve blockade with 2% lidocaine for 12 weeks was superior to placebo in decreasing the average number of headache and migraine days in patients with chronic migraine with a good tolerability profile.Clinical trial.gov no. CTRI 2020/07/026709.

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.

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.

Personal protective equipment-associated headaches in health care workers during COVID-19: A systematic review and meta-analysis

Introduction

Health Care Workers (HCWs) use Personal Protective Equipment (PPE) during the COVID-19 pandemic to protect themselves and prevent the transmission of the disease. The use of PPE, especially respiratory masks, has adverse consequences, including headaches, which have been secondary and unusual. The aim of the present systematic review and meta-analysis study was to investigate the prevalence of PPE-associated headaches in HCWs during COVID-19 pandemic.

Methods

The present review study was performed based on the PRISMA guideline. The protocol of the present study was registered in PROSPERO with the code CRD42022304437. Valid data resources such as Scopus, PubMed, Web of Science, Science Direct, Google Scholar, Embase were used to identify and extract relevant studies. The searches were conducted between the beginning of 2020 and the end of January 2022. A random effects model was used for meta-analysis and I ² index was used to investigate between-study heterogeneity. Data were analyzed using STATA ver. 14.

Results

A total of 539 articles were first identified through initial search and finally 26 final studies were selected to undergo the meta-analysis phase. According to the results of meta-analysis, the prevalence of headache after and before the use of PPE was 48.27% (95% CI: 40.20-56.34, I ² = 99.3%, p = 0 < 001) and 30.47% (95% CI: 20.47-40.47, I ² = 97.3%, p = 0 < 001), respectively.

Conclusion

The results of the present study showed that the prevalence of PPE-associated headache in HCWs was relatively high, so, the use of PPE during COVID-19 pandemic can be considered as one of the causes of headache. Therefore, management strategies such as regular screening of HCWs for headaches and regular rest periods without the use of PPE can be effective in reducing the prevalence of headaches.

Effectiveness, Safety, and Predictors of Response to 5% Lidocaine-Medicated Plaster for the Treatment of Patients With Trigeminal Neuralgia: A Retrospective Study

BACKGROUND

Whether 5% lidocaine-medicated plaster (LMP) is a valuable therapeutic option for the treatment of trigeminal neuralgia (TN) is worth exploring. If LMP is proven effective for TN, positive predictors of the analgesic effects of LMP warrant further investigation.

OBJECTIVE

To evaluate the efficacy and safety of LMP for the treatment of TN, and to explore the predictive factors for the treatment efficacy of LMP.

METHODS

This is a retrospective and observational study. We analyzed the efficacy of LMP for the treatment of TN between March 2019 and January 2022. The follow-up time was approximately 2 weeks, 1 month, 2 months, and 3 months after LMP treatment. The LMP response was considered the Barrow Neurological Institute (BNI) score of I to III and an improvement in BNI of at least I grade from pretreatment baseline. Univariable and multivariable logistic analyses were performed to identify the predictive factors for LMP response.

RESULTS

A total of 103 patients were included and analyzed in this study. LMP was effective in some TN patients, with an efficacy rate of 21.4%, 21.4%, 18.4%, and 16.5% after 2 weeks, 1 month, 2 months, and 3 months of LMP treatment, respectively. The overall adverse event rate associated with LMP was 5.8%, and the reported adverse events were all skin reactions. Facial trigger points (odds ratio [OR] = 0.25, 95% confidence interval [CI] = 0.07-0.86, P = 0.03) and a lower BNI score (OR = 0.37, 95% CI = 0.07-0.87, P = 0.01) were identified as potential predictors for initial efficacy (2-week follow-up) of LMP treatment.

CONCLUSIONS AND RELEVANCE

LMP has been shown to provide effective and sustained analgesia in some TN patients with minimal risk of systemic adverse reactions. Patients with facial trigger points and mild to moderate pain are more likely to benefit from LMP treatment. Our data suggest that LMP may be an effective treatment option for patients with the aforementioned characteristics of TN.

Nonsurgical Treatment of Neuralgia and Cervicogenic Headache: A Systematic Review and Meta-analysis

Background:

Extracranial compression of peripheral sensory nerves is one of many origins of chronic headaches. Identifying these patients can be difficult, and they are often diagnosed with neuralgia or cervicogenic headache. The recent literature provides the outcomes of surgical decompression in patients with these headaches. This study aimed to give an overview of the current literature on the nonsurgical treatment options and to evaluate the effectiveness of these treatments in patients with neuralgia and cervicogenic headache.

Methods:

Databases were searched to identify all published clinical studies investigating nonsurgical treatment outcomes in patients with neuralgia or cervicogenic headaches. Studies that reported numerical pain scores, nonnumerical pain scores, headache-free days, or the number of adverse events after nonsurgical treatment were included.

Results:

A total of 22 articles were included in qualitative analysis. The majority of studies included patients who received injection therapy. Treatment with oral analgesics achieved good results in only 2.5% of the patients. Better outcomes were reported in patients who received local anesthetics injection (79%) and corticosteroid injection (87%). Treatment with botulinum toxin injection yielded the highest percentage of good results (97%; 95% CI, 0.81–1.00). The duration of headache relief after injection therapy varied from 30 minutes to 5 months.

Conclusions:

The nonsurgical treatment of patients with neuralgia or cervicogenic headache is challenging. Injection therapy in patients with these types of headaches achieved good pain relief but only for a limited time. Surgical decompression may result in long-lasting pain relief and might be a more sustainable treatment option.

Integrative, Interventional, and Non-invasive Approaches for the Treatment for Migraine During Pregnancy

PURPOSE OF REVIEW

While most women with migraine improve during pregnancy, a subset may remain unchanged or even become more severe. Given the limited evidence for the use of prescription medications during pregnancy, many look to other treatment modalities. We seek to review complementary and integrative medicine, procedural interventions, and neurostimulation to empower women with safe and effective treatment options during pregnancy.

RECENT FINDINGS

Migraine treatment during pregnancy remains controversial. While evidence is limited, prospective and retrospective reviews, as well as clinical experience support the use of nutraceuticals, procedural interventions, and neurostimulation during pregnancy when the appropriate risks and benefits are weighed. Empowering patients with information on complementary and integrative medicine, as well as non-systemic and interventional treatments, may help to reduce anxiety and headache burden during pregnancy. Various nutraceuticals have shown promise for the preventive management of migraine. Non-systemic interventions such as trigger point injections and peripheral and sphenopalatine nerve blocks offer effective treatment options with minimal side-effects. Options for neurostimulation have expanded in recent years and may offer safe and effective non-pharmacologic options for the management of migraine. It is imperative that providers do not minimize migraine during pregnancy and become aware of the treatment modalities available to help guide women through this experience.

Efficacy and tolerability of combination treatment of topiramate and greater occipital nerve block versus topiramate monotherapy for the preventive treatment of chronic migraine: A randomized controlled trial

OBJECTIVE

To compare the efficacy and tolerability of combination treatment of topiramate and greater occipital nerve block to topiramate monotherapy in adult chronic migraine patients.

BACKGROUND

Options for the preventive treatment of chronic migraine are limited and costly. Combination treatments do not have an evidence base yet.

METHODS

This was a parallel group, 3 arms with 1:1:1 allocation ratio randomized controlled study in consecutive adult chronic migraine patients attending Headache Clinic in a tertiary care hospital. Patients received either topiramate monotherapy 100 mg/day (group A), or topiramate plus greater occipital nerve block with 40 mg lidocaine (2%) and 80mg (2 ml) methylprednisolone as the first injection followed by monthly injections of lidocaine for the next 2 months (group B) or topiramate plus greater occipital nerve block with 40 mg lidocaine (2%) injections monthly for 3 months (group C). The primary endpoint was the mean change in monthly migraine days at Month 3. Multiple secondary endpoints were assessed that included among others, achievement of ≥50% reduction in mean monthly headache days compared to baseline at Month 3 and assessment for any adverse events.

RESULTS

One hundred and twenty-five patients were randomized; 41 to group A, 44 to group B, and 40 to group C. Efficacy assessments were done for 121 patients. Patients receiving combination treatment of topiramate and greater occipital nerve block with steroids and lidocaine and greater occipital nerve block with only lidocaine compared to topiramate monotherapy showed greater reductions in monthly migraine days at Month 3 (-9.6 vs -7.3 days; p = 0.003) and (-10.1 vs -7.3 days; p < 0.001) respectively. Greater proportion of patients in both the combination treatment groups (added greater occipital nerve block with and without steroid) achieved ≥50% reduction in mean monthly headache days [71.4% vs 39%; OR (95% CI) 3.9(1.6-9.8); p = 0.004] and [62.4% vs 39%; OR (95% CI) 2.7(1.1-6.7); p = 0.034] respectively, compared to those receiving topiramate monotherapy. Adverse effects between the groups were comparable although patients receiving combination treatment with added greater occipital nerve block reported transient adverse effects like post-injection dizziness, local site swelling, and pain. No serious adverse event was reported.

CONCLUSION

Combination treatments of topiramate with monthly injections of greater occipital nerve block were more effective in reducing monthly migraine days in chronic migraine than topiramate monotherapy at Month 3. Combination treatments were well tolerated.

Preventive effect of greater occipital nerve block on patients with episodic migraine: A randomized double-blind placebo-controlled clinical trial

OBJECTIVE

Since the data regarding the efficacy of greater occipital in episodic migraines are rare, we aimed to examine the efficacy of greater occipital block in the prophylaxis of episodic migraines without aura and compare different injectable drug regimens.

METHODS

In a randomized, double-blind placebo-controlled trial, adult patients suffering from episodic migraines without aura were randomized to one of the following: triamcinolone, lidocaine, triamcinolone plus lidocaine, and saline. Patients were assessed at baseline, one week, two weeks, and four weeks after the injection for severity and duration of headaches and side effects.

RESULTS

Fifty-five patients completed the study. Repeated measures ANOVA indicated that the severity and duration decreased significantly after the greater occipital block (P < 0.001, P = 0.001 respectively) in all four groups. However, there was no difference between groups at any study time points (P > 0.05). In paired sample T-test, only groups 2 and 3 with lidocaine as a part of the injection showed a significant decrease in frequency compared to the baseline (P = 0.002, P = 0.019). Three patients reported side effects with a possible association with triamcinolone.

CONCLUSION

Greater occipital block with a local anesthetic significantly decreases the number of attacks in episodic migraine, whereas no injection was superior to the placebo in regards to the duration and severity of the headaches.Trial Registration Information: Iranian Registry of Clinical Trials (IRCT). Registration number: IRCT2017070334879N1. https://www.irct.ir/trial/26537.

Ultrasound-Guided Occipital Nerve Block for Treatment of Atypical Occipital Neuralgia

Occipital neuralgia can occur secondary to injury to the occipital nerves or the C2 or C3 nerve roots. Symptoms of occipital neuralgia can include sudden and debilitating craniofacial pain, otalgia, neck pain, shoulder pain, vision changes, and tinnitus. We describe how an ultrasound-guided greater occipital nerve block substantially reduced symptoms associated with a middle-aged woman’s atypical presentation of occipital neuralgia, which was refractory to oral medications and other procedural interventions.

Regional Anaesthetic Techniques and Their Implications During the COVID Pandemic

The current pandemic has highlighted the need to protect both patients and medical staff. The increased use of regional anaesthesia as a primary anaesthetic modality for operations and other invasive procedures has limited the number of aerosol-generating procedures performed during general anaesthesia. Its use is further characterized by decreases in postoperative pain and length of hospitalization. This article provides an overview of regional anaesthetic techniques (peripheral nerve locks, epidural and spinal anaesthesia) and their uses during the COVID pandemic.

Correlates of post-dural puncture headache and efficacy of different treatment options: a monocentric retrospective study

Background:

Post-dural puncture headache (PDPH) is a severe positional headache that appears usually within 72 hours after inadvertent dural puncture, secondary to cerebrospinal fluid leakage. It is treated first by conservative treatment (including bed rest, hydration, caffeine and simple analgesia) and then by invasive procedures such as blood patch. This study aims to evaluate factors associated with PDPH among a sample of Lebanese patients and assess the rate of success of different treatment modalities administered in a specific sequence: conservative treatment first, then ultrasound-guided bilateral greater occipital nerve block (GONB) if failure of conservative treatment and finally epidural blood patch (EBP) if failure of GONB.

Methods:

A retrospective case–control study was conducted between January 2015 and December 2019 in the Notre-Dame des Secours University Hospital. Out of a total of 10,051 procedures, 18 cases were diagnosed with PDPH and were matched based on gender, age and procedure type to a control group of patients who did not develop PDPH randomly selected (72 patients).

Results:

Higher body mass index (adjusted odds ratio (ORa) = 0.77) was significantly associated with lower odds of PDPH, whereas the presence of previous chronic headache (ORa = 5.56) was significantly associated with higher odds of PDPH. Seven out of 18 (38.89%) had their pain symptoms/headache resolved on conservative treatment. Out of the remaining 11 patients, 6 (33.33%) had their symptoms resolved on GONB with a significant decrease in the pain score 48 hours after GONB compared to baseline (5.55 vs 9.73; p = 0.007). Five patients (27.78%) had their symptoms resolved using a blood patch, with a significant decrease in the pain score after blood patch compared to baseline (3.00 vs 9.80; p = 0.041).

Conclusion:

Our preliminary data suggest that ultrasound-guided GONB is a minimally risky and efficacious technique for those who fail to respond to conservative treatment.

Comprehensive management of adults with chronic migraine: Clinical practice guidelines in Mexico

Introduction:

Migraine is a polygenic multifactorial disorder with a neuronal initiation of a cascade of neurochemical processes leading to incapacitating headaches. Headaches are generally unilateral, throbbing, 4–72 h in duration, and associated with nausea, vomiting, photophobia, and sonophobia. Chronic migraine (CM) is the presence of a headache at least 15 days per month for ≥3 months and has a high global impact on health and economy, and therapeutic guidelines are lacking.

Methods:

Using the Grading of Recommendations, Assessment, Development, and Evaluations system, we conducted a search in MEDLINE and Cochrane to investigate the current evidence and generate recommendations of clinical practice on the identification of risk factors and treatment of CM in adults.

Results:

We recommend avoiding overmedication of non-steroidal anti-inflammatory drugs (NSAIDs); ergotamine; caffeine; opioids; barbiturates; and initiating individualized prophylactic treatment with topiramate eptinezumab, galcanezumab, erenumab, fremanezumab, or botulinum toxin. We highlight the necessity of managing comorbidities initially. In the acute management, we recommend NSAIDs, triptans, lasmiditan, and gepants alone or with metoclopramide if nausea or vomiting. Non-pharmacological measures include neurostimulation.

Conclusions:

We have identified the risk factors and treatments available for the management of CM based on a grading system, which facilitates selection for individualized management.

Comparison of greater occipital nerve and supra orbital nerve blocks methods in the treatment of acute migraine attack: A randomized double-blind controlled trial

OBJECTIVE

The main goal of this investigation is to compare the Greater Occipital Nerve (GON) and Supra Orbital Nerve (SON) block methods used in the treatment of migraine attacks in the ED with each other, in combination, and with a placebo.

METHODS

This study was planned as a single center, prospective, double-blind, randomized control study. The patients were divided into 4 groups: GON, SON, Combined, and Placebo. Groups were named according to the nerve areas that were blocked. Therefore1% lidocaine for nerve blockade and 0.9% NaCl for placebo effect was used. Along with the time of admission, baseline pain scale values, as well as recordings at 30 and 60 min in addition to the Visual Analog Scale (VAS) at the 120th min. and Likert-Type (LT) Verbal scale at the 120th min. were measured. The primary outcome of this study was a change in the VAS and LT values at the 0-120th minute after treatment RESULTS: In this study, 128 patients in 4 groups were included in the analysis. In the GON group, SON group, and Combined group, the change observed at the 120th minute scores compared to baseline VAS scores was higher than Placebo group [OR (95% CI) = -17.4 (-24.8, -9.9), 32.1 (23.8, 40.3), 49.5 (41.9, 57), respectively]. In inter-group comparison, it was found that the VAS and LT scores of the Combined group and the GON group improved at a higher rate than the SON group CONCLUSIONS: SON blockade, GON blockade, and a combination of these two blockades are effective treatment methods in acute migraine attack. Performing a GON or Combined blockade for migraine attack causes greater pain reduction than SON blockade.

Focused Ultrasound (FUS) for Chronic Pain Management: Approved and Potential Applications

Chronic pain is one of the leading causes of disability and disease burden worldwide, accounting for a prevalence between 6.9% and 10% in the general population. Pharmacotherapy alone results ineffective in about 70-60% of patients in terms of a satisfactory degree of pain relief. Focused ultrasound is a promising tool for chronic pain management, being approved for thalamotomy in chronic neuropathic pain and for bone metastases-related pain treatment. FUS is a noninvasive technique for neuromodulation and for tissue ablation that can be applied to several tissues. Transcranial FUS (tFUS) can lead to opposite biological effects, depending on stimulation parameters: from reversible neural activity facilitation or suppression (low-intensity, low-frequency ultrasound, LILFUS) to irreversible tissue ablation (high-intensity focused ultrasounds, HIFU). HIFU is approved for thalamotomy in neuropathic pain at the central nervous system level and for the treatment of facet joint osteoarthritis at the peripheral level. Potential applications include HIFU at the spinal cord level for selected cases of refractory chronic neuropathic pain, knee osteoarthritis, sacroiliac joint disease, intervertebral disc nucleolysis, phantom limb, and ablation of peripheral nerves. FUS at nonablative dosage, LILFUS, has potential reversible and tissue-selective effects. FUS applications at nonablative doses currently are at a research stage. The main potential applications include targeted drug and gene delivery through the Blood-Brain Barrier, assessment of pain thresholds and study of pain, and reversible peripheral nerve conduction block. The aim of the present review is to describe the approved and potential applications of the focused ultrasound technology in the field of chronic pain management.

Comparison of greater occipital nerve and greater occipital nerve + supraorbital nerve block effect in chronic medication overuse headache

Background /aim

In this study, we aimed to compare the efficacy of greater occipital nerve (GON) block alone and GON combined with supraorbital nerve (SON) block in the treatment of medication overuse headache (MOH).

Material and methods

82 patients were divided into two groups: 41 patients were administered bilateral GON block while the other 41 patients GON + SON block. Nerve blocks were administered every 10 days for a total of 5 sessions. After each administration and 20 days after the last injection, information on pre and post treatment numerical rating scale (NRS) score, number of painful days, analgesic intake, duration of pain were collected.

Results

The decrease in headache evaluation parameters was similar in both groups after the block. The NRS scores in the GON and GON + SON groups before the treatment was (8.2 ± 0.7, 8.5 ± 0.7), the number of painful days in a month was (21.4 ± 6.9, 21.2 ± 4.6 days), the number of analgesics taken monthly was (45 ± 25.6, 47.5 ± 29.9), the duration of pain was (44.9 ± 24.6, 41.7 ± 22.8 h), respectively. On the 60th day of treatment, the NRS scores in the GON and GON + SON groups were found to be (6.8 ± 2.5, 4.8 ± 2.3), the number of painful days in a month was (4.2 ± 3.3, 2.2 ± 1.5), respectively. The number of monthly analgesic consumption was (4.4 ± 3.8, 0.9 ± 1.2), and the duration of pain was (28.4 ± 19.3, 19.4 ± 16.1 h).

Conclusion

This study showed significant reductions in headache parameters in both groups. However, NRS score, analgesic intake, number of painful days, and pain duration significantly better improved in the GON block added SON block group.

Occipital Neuralgia: Advances in the Operative Management

Background

Occipital neuralgia (ON) is a primary headache disorder characterized by sharp, shooting, or electric shock-like pain in the distribution of the greater, lesser, or third occipital nerves.

Aim

To review the existing literature on the management of ON and to describe our technique of an endoscopic-assisted approach to decompress the GON proximally in areas of fibrous and muscular compression, as well as distally by thorough decompression of the occipital artery from the nerve.

Methods

Relevant literature on the medical and surgical management of ON was reviewed. Literature on the anatomical relationships of occipital nerves and their clinical relevance were also reviewed.

Results

While initial treatment of ON is conservative, peripheral nerve blocks and many surgical management approaches are available for patients with pain refractory to the medical treatment. These include greater occipital nerve blocks, occipital nerve stimulation, Botulinum toxin injections locally, pulsed radiofrequency ablation, cryoneuroablation, C-2 ganglionectomy, and endoscopic-assisted ON decompression.

Conclusion

Patients of ON refractory to medical management can be benefitted by surgical approaches and occipital nerve blocks. Endoscopic-assisted ON decompression provides one such approach for the patients with vascular, fibrous or muscular compressions of occipital nerves resulting in intractable ON.

Cranial Neuralgias

PURPOSE OF REVIEW

This article discusses the differential diagnosis, evaluation, and management of trigeminal neuralgia and reviews other neuralgias of the head and neck, including those that contribute to neuralgic ear pain.

RECENT FINDINGS

Most cases of trigeminal neuralgia are related to vascular compression, a demyelinating plaque, or a compressive mass affecting the trigeminal nerve. However, recent studies have shown that up to 11% of patients have a family history of trigeminal neuralgia, suggesting that some patients may have a genetic predisposition to demyelination or nerve hyperexcitability. In these patients, trigeminal neuralgia may occur at a younger age, on both sides of the face, or in combination with other neuralgias.

SUMMARY

When a patient presents with neuralgic pain, the diagnosis is made by careful history and neurologic examination, with attention to the dermatome involved, the triggers, and the presence of any associated sensory deficit. All patients with new neuralgia or neuropathic facial pain warrant a careful evaluation for a secondary cause. The presence of sensory deficit on bedside examination is particularly concerning for an underlying secondary etiology.

Clinic-based Procedures for Headache

PURPOSE OF REVIEW

Headache disorders are common and disabling, and many therapies that are effective and safe are procedural.

RECENT FINDINGS

After pivotal clinical trials, onabotulinumtoxinA has become an established preventive therapy for chronic migraine; it is better tolerated than many other treatments and may be useful for other headache disorders. Peripheral nerve blocks, especially greater occipital nerve blocks, have amassed evidence from randomized trials in the acute and short-term preventive treatment of migraine and cluster headache. Trigger point injections and sphenopalatine ganglion blocks have recent trials suggesting efficacy and safety in properly selected patients. Medical education initiatives are needed to train neurologists in these procedures to help manage the large population of patients with headache disorders who need them.

SUMMARY

Evidence exists for the efficacy and safety of procedural therapies to be incorporated into neurology practice for the management of patients with migraine, cluster headache, and other headache disorders.

Occipital Nerve Blockade for the Treatment of Occipital Neuralgia-Like Acute Postcraniotomy Headache: A Retrospective Study

Objective

The therapeutic effectiveness and safety of occipital nerve blockade (ONB) on occipital neuralgia- (ON-) like acute postcraniotomy headache (ON-APCH) was evaluated.

Background

Persistent occipital neuralgia is a subclassification of chronic postcraniotomy headache and has been investigated sporadically in previous publications. The long-lasting neuralgic pain significantly impairs postoperative recovery and quality of life. However, little is known regarding ON-APCH and its management.

Methods

All data were retrospectively acquired from consultation records and electronic institutional medical documents. Forty-one patients, who developed drug-resistant ON-APCH after elective craniotomy and received ONB with lidocaine for diagnoses, were included in this study, all of whom were treated using dexamethasone and lidocaine. Pain intensity and ONB correlated complications and side effects were collected and analyzed at three different time points: before ONB, at 1 day after ONB, and at discharge.

Results

Nineteen males and twenty-two females aged 49.6 ± 15.2 years were diagnosed with drug-resistant ON-APCH. The mean NRS was 8.0 ± 0.9 before ONB, which later significantly decreased to 2.1 ± 1.4 and 1.6 ± 0.6 at 1 day after ONB and on discharge, respectively. At 1 month after ONB, thirty patients (73%) obtained complete pain relief without medication. At 3 months after ONB, only two (5%) patients had to continue oral medications to maintain pain relief. No adverse effects or complications were observed immediately after, or within 3 months, of the nerve blockade.

Conclusions

For drug-resistant ON-APCH, early occipital nerve blockade with dexamethasone and lidocaine is an effective and safe technique, which provides adequate pain relief and may prevent further development of persistent presentation of refractory ON.

Clinical success of greater occipital nerve blockade in improving sleep quality of chronic migraineurs: a prospective observational study

BACKGROUND

The success of various therapy methods in the treatment of insomnia and poor quality sleep, both of which play an active role in the chronicization process of migraine, has been the subject of investigation. The aim of this research was to evaluate the success, acceptability, and efficacy of greater occipital nerve block (GON-B) therapy in chronic migraine (CM) patients in improving their sleep quality and developing their beliefs about sleep .

METHODS

The study included 40 patients with CM from the general population who agreed to receive blockade therapy. Before the injection treatment, 1-week sleep diaries as well as depression and anxiety symptoms were examined. The Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Pre-Sleep Arousal Scale (PSAS), Epworth Sleepiness Scale (ESS), and Dysfunctional Beliefs and Attitudes about Sleep (DBAS) scales were measured and evaluated both before and after the completion of 3 months of treatment.

RESULTS

Thirty-seven patients with CM successfully completed our 12-week treatment period. The anxiety and depression scales of the patients decreased after 3 months (p < 0.001). PSQI and its subgroups ratings significantly improved after treatment (p < 0.001). Similarly, ISI, ESS, PSAS, and DBAS test scores also improved after treatment (p < 0.001).

CONCLUSIONS

This study provides evidence as to the applicability and acceptability of GON-B in CM treatment in terms of increased sleep quality; improved sleep beliefs, attitudes, and behaviors; and arousals and decreased insomnia findings.

Improving Acute Treatment of Pediatric Primary Headache Disorders With a Novel Headache Treatment Center: Retrospective Review of Preliminary Outcomes

OBJECTIVE

To determine preliminary outcomes of targeted headache treatments provided at a novel outpatient acute care pediatric headache treatment center.

BACKGROUND

Limitations exist in acute management of pediatric headaches, including inadequate access to specialty headache therapies and headache specialists in acute settings, variable success of emergency room treatments, and omission of comfort measures. An outpatient acute headache care clinic (the "Headache Treatment Center") was strategically initiated at a Midwestern pediatric academic hospital to provide acute and targeted headache therapies for children with active headaches.

METHODS

We conducted a retrospective chart review of 154 visits from September through November 2018 of patients ages 7-18 years visiting the Headache Treatment Center.

RESULTS

On average, headache intensity (measured on an 11-point pain numeric rating scale) decreased after interventions used in the Headache Treatment Center (mean change = 2.85 ± 2.81, P < .05, Cohen d = 1.01). Large effect sizes for reducing headache intensity were observed for pericranial, occipital/auriculotemporal, and occipital nerve blocks, Cohen d = 1.56, 1.64 and 1.02, respectively. Large effect sizes for reducing headache intensity also were observed for a transcutaneous supraorbital nerve stimulator device (Cefaly) (Cohen d = 1.02), acupuncture (Cohen d = 1.09), and intravenous migraine cocktails (Cohen d = 0.91-1.34).

CONCLUSION

Targeted headache therapies to abort pediatric primary headaches as part of a novel headache clinic model may be beneficial for short-term management.

Interventional Procedures in Episodic Migraine

Purpose of Review

Migraine is a common disorder which in many cases can be adequately treated with medications. However, there are some patients who may either not respond to medications or have contraindications to their use. In this review, we will evaluate the available literature on the interventional procedures available to treat patients with episodic migraine. We will review the technical details of performing the procedures, the potential mechanisms of action, and available data on their effectiveness.

Recent Findings

Recent studies conducted on the subject of interventional procedures including peripheral nerve blocks and onabotulinumtoxinA indicate that some patients with episodic migraine may find benefit from such procedures.

Summary

In patients with episodic migraine whom traditional treatments have not been effective or are contraindicated, interventional procedures may offer an opportunity to provide additional treatment options.

Addition of corticosteroids to local anaesthetics for chronic non-cancer pain injections: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Despite common use, the benefit of adding steroids to local anaesthetics (SLA) for chronic non-cancer pain (CNCP) injections is uncertain. We performed a systematic review and meta-analysis of English-language RCTs to assess the benefit and safety of adding steroids to local anaesthetics (LA) for CNCP.

METHODS

We searched MEDLINE, EMBASE, and CENTRAL databases from inception to May 2019. Trial selection and data extraction were performed in duplicate. Outcomes were guided by the Initiative in Methods, Measurements, and Pain Assessment in Clinical Trials (IMMPACT) statement with pain improvement as the primary outcome and pooled using random effects model and reported as relative risks (RR) or mean differences (MD) with 95% confidence intervals (CIs).

RESULTS

Among 5097 abstracts, 73 trials were eligible. Although SLA increased the rate of success (42 trials, 3592 patients; RR=1.14; 95% CI, 1.03-1.25; number needed to treat [NNT], 13), the effect size decreased by nearly 50% (NNT, 22) with the removal of two intrathecal injection studies. The differences in pain scores with SLA were not clinically meaningful (54 trials, 4416 patients, MD=0.44 units; 95% CI, 0.24-0.65). No differences were observed in other outcomes or adverse events. No subgroup effects were detected based on clinical categories. Meta-regression showed no significant association with steroid dose or length of follow-up and pain relief.

CONCLUSIONS

Addition of cortico steroids to local anaesthetic has only small benefits and a potential for harm. Injection of local anaesthetic alone could be therapeutic, beyond being diagnostic. A shared decision based on patient preferences should be considered. If used, one must avoid high doses and series of steroid injections.

CLINICAL TRIAL REGISTRATION

PROSPERO #: CRD42015020614.

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.

Peripheral nerve blocks for headache disorders

Headache is a common neurological referral and a frequent cause for acute hospital admissions. Despite peripheral nerve blocks being widely used in headache and pain services to treat patients with headache disorders, there is no readily accessible resource with instructions for the delivery of peripheral nerve blocks. Here we provide a practical approach for administering peripheral nerve blocks and cover the current evidence base for such procedures in different headache disorders. We provide instructions and an audiovisual guide for administering greater and lesser occipital, supratrochlear, supraorbital and auriculotemporal nerves blocks, and give information on their adverse effects and potential complications. This information will provide a reference for headache practitioners when giving peripheral nerve blocks safely to people with headache.

Craniofacial neuralgias

While non-headache, non-oral craniofacial neuralgia is relatively rare in incidence and prevalence, it can result in debilitating pain. Understanding the relevant anatomy of peripheral branches of nerves, natural history, clinical presentation, and management strategies will help the clinician better diagnose and treat craniofacial neuralgias. This article will review the nerves responsible for neuropathic pain in periorbital, periauricular, and occipital regions, distinct from idiopathic trigeminal neuralgia. The infratrochlear, supratrochlear, supraorbital, lacrimal, and infraorbital nerves mediate periorbital neuralgia. Periauricular neuralgia may involve the auriculotemporal nerve, the great auricular nerve, and the nervus intermedius. The greater occipital nerve, lesser occipital nerve, and third occipital nerve transmit occipital neuralgias. A wide range of treatment options exist, from modalities to surgery, and the evidence behind each is reviewed.