50% Reduction in Migraines by Occipital Nerve Blocks

There are now 4 different reports demonstrating good results form nerve blocks for headaches – they are separated into groups. Using 5-10% lidocaine helps but not all that safe in elderly.

  1. Latest article:

J Headache Pain. 2018 Aug 20;19(1):73. doi: 10.1186/s10194-018-0901-z.
Neurophysiological correlates of clinical improvement after greater occipital nerve (GON) block in chronic migraine: relevance for chronic migraine pathophysiology.
Viganò A et al
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6102162/pdf/10194_2018_Article_901.pdf

Treatment process:
“Bilateral GON blocks were performed with a 21-gauge needle, injecting suboccipitally midway between inion and mastoid, a 3 ml solution of betamethasone sodium
phosphate 4 mg (2 ml) and xylocaine 2% (1 ml)”

Results:
Occipitalblocks 2018

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2) Long previous studies

I’ve written about Nerve blocks before: – large review:

Quick Fix For Headaches – Repeated Nerve Supraorbital, Infraorbital, and Occipital Nerve Blocks – and What To Do For The Very Bad
http://painmuse.org/?p=2886

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3) Later Report here:
Several protocols had been made up. This present one, was weekly Occipital Nerve Blocks either unilateral or bilateral for one month and then monthly thereafter. After 3 months, headache frequency was cut about in 1/2, and the headaches were some shorter and a bit less severe. This is a good or better than botulinum but if used in combo should give great results.

Neurol Sci. 2017 Feb 28. doi: 10.1007/s10072-017-2861-5. [Epub ahead of print]
Do bilateral and unilateral greater occipital nerve block effectiveness differ in
chronic migraine patients?
Ünal-Artık HA
https://www.ncbi.nlm.nih.gov/pubmed/28247118

  • 42 patients with an average of 20 migraines/month

occipital nerve blocks

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4) 10% lidocaine augmentation

Finally a way of augmenting the shots with using 10% lidocaine (do not use in elderly as tolerance is poor even for 5% lidocaine – see Sahai-Srivastava ref below )

J Pain Res. 2016 Sep 29;9:721-725. Prolongation of greater occipital neural blockade with 10% lidocaine neurolysis:A case series of a new technique.Kim DD et al
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5047742/pdf/jpr-9-721.pdf

  • 60% reduction in migraine (10) or Occipital Neuraliga (3)  for 148.05 +/- 98.87 days

 

Comment – I use 5% lidocaine as its use has been documented before and is easy to use as long as you stay at 2 ml for average adult and 1.5 mls for elderly.
J Headache Pain. 2010 Dec;11(6):519-23. doi: 10.1007/s10194-010-0244-x.
Adverse effect profile of lidocaine injections for occipital nerve block in occipital neuralgia.
Sahai-Srivastava S et al
https://www.ncbi.nlm.nih.gov/pubmed/20665065

I put about 0.5 mls into each tender location:
– 3rd occipital nerve near midline – Greater Occipital nerve maybe 2.5 cm laterally
–  Lesser Occipial nerve – half way out from there to ear

You can feel tracts where neurovascular bundles run. press firmly down on them so they can’t move. Make sure you bend needle 30 degrees and try to run parallel into nerve.  With nerve trapped it is easy to get a tinels. I use a 30 gauge needle unless heavyset. Don’t try injecting steroid through a 30 gauge though…

Steroids are unnecessary unless they have had a constant headache for days (A status migraine) in which case 40 ml triamcinolone  IM helps. In study below they compared results to injecting steroids – only got 6 days relief from steroids.

Comment – I stick to 5% lidocaine intially – 2 mls total and half that for elderly or small cases. I have found adding fine particulate methylene blue ( not particularly water soluble) makes it last longer…

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