Background Greater occipital nerve (GON) blocks are widely used for the treatment of headaches, but quality evidence regarding their efficacy is scarce. Objective The objective of this article is to assess the short-term clinical efficacy of GON anaesthetic blocks in chronic migraine (CM) and to analyse their effect on pressure pain thresholds (PPTs) in different territories. Participants and methods The study was designed as a double-blind, randomised, placebo-controlled clinical trial. Thirty-six women with CM were treated either with bilateral GON block with bupivacaine 0.5% ( n = 18) or a sham procedure with normal saline ( n = 18). Headache frequency was recorded a week after and before the procedure. PPT was measured in cephalic points (supraorbital, infraorbital and mental nerves) and extracephalic points (hand, leg) just before the injection (T0), one hour later (T1) and one week later (T2). Results Anaesthetic block was superior to placebo in reducing the number of days per week with moderate-or-severe headache (MANOVA; p = 0.027), or any headache ( p = 0.04). Overall, PPTs increased after anaesthetic block and decreased after placebo; after the intervention, PPT differences between baseline and T1/T2 among groups were statistically significant for the supraorbital (T0-T1, p = 0.022; T0-T2, p = 0.031) and infraorbital sites (T0-T1, p = 0.013; T0-T2, p = 0.005). Conclusions GON anaesthetic blocks appear to be effective in the short term in CM, as measured by a reduction in the number of days with moderate-to-severe headache or any headache during the week following injection. GON block is followed by an increase in PPTs in the trigeminal area, suggesting an effect on central sensitisation at the trigeminal nucleus caudalis. This trial is registered at ClinicalTrials.gov (NCT02188394).

Qualitative research offers insight into the way CH patients experience their disease, and may be helpful in establishing a fruitful relationship with these patients.

Nummular headache (NH) is characterized by continuous or intermittent head pain, which remains confined to a round or oval shaped area of the scalp, generally 1 to 6 cm in diameter. Usually mild or moderate in intensity, some patients suffer severe acute exacerbations or continuous disabling pain. Areas covered: This article reviews epidemiological and clinical features of NH, the most recently proposed pathophysiological mechanisms, and state-of-the-art management according to the literature. Expert commentary: Information regarding true incidence and prevalence is lacking, but NH is a fairly common disorder in patients attending a headache clinic. Diagnostic work-up requires the exclusion of systemic and structural disease by a thorough physical examination, blood tests including immunology screening, and neuroimaging. No clinical trials have been conducted for NH, so the level of evidence for any treatment is low. Gabapentin seems to be the most effective oral medication; subcutaneous injection of the area with onabotulinum toxin type A also seems to be effective, and should be considered as an alternative to gabapentin.

In selected patients with nummular headache, vascular imaging of the scalp may reveal anomalies amenable to surgical treatment or triptan administration, sometimes resulting in disappearance of the pain.

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