Greater occipital nerve injection in primary headache syndromes – prolonged effects from a single injection

Abstract

Most patients with primary headache syndromes who have frequent attacks of pain have tenderness in the sub-occipital region. Injection of the greater occipital nerve (GON) with local anesthetic and corticosteroids has been widely used in clinical practice for many years, yet there is no clear understanding of its mechanisms of action. Moreover, there is no current gold-standard of practice regarding GON injections in the management of headache. We audited of our practice to generate hypotheses about the range of primary headaches that might benefit, to determine response rates to power future studies, and to assess whether we should continue to do this procedure. Twenty-six of fifty-seven injections in 54 migraineurs yielded a complete or partial response that lasted for the partial response a median of 30 days. For cluster headache 13 of 22 injections yielded a complete or partial response lasting for a median of 21 days for the partial response. Tenderness over the GON was strongly predictive of outcome, although local anesthesia after the injection was not. The presence or absence of medication overuse did not predict outcome. Apart from two patients with a small patch of alopecia the injection was well tolerated. GON injection is a useful tool in some patients that provides interim relief while other approaches are explored. It is remarkable that in all conditions in which an effect is observed the response time so much exceeds the local anesthetic effect that the mechanism of action may well be through changes in brain nociceptive pathways.

Surgical Interventions for Cluster Headache, Including Implanted Stimulators

“…Some open label and uncontrolled studies (Peres et al 2002;Afridi et al 2006) and a double-blind placebo-controlled trial (Ambrosini et al 2005) now support the efficacy of GON block. A mixture of the local anesthetic lidocaine and a corticosteroid, such as betamethasone (Ambrosini et al 2005), triamcinolone (Peres et al 2002) and methylprednisolone (Afridi et al 2006), is generally injected. The efficacy of the injection does not seem to be related to the lidocaine in the solution, but rather to the corticosteroid (Anthony 1985;Ambrosini et al 2005).…”

The Results of Greater Occipital Nerve Block Applied for Migraine Headache

“…Nadir olgularda boyun ağrısı ve baş dönmesi yapabilir. Afridi ve arkadaşları [14] primer başağrısı olan 101 hastalık ça-lışmalarında 1 hastada vazovagal senkop, 3 hastada geçici uyuşukluk, 2 hastada enjeksiyon yerinde alopesi gözlenmiş. Shields ve arkadaşları [15] 100 hastalık çalışmalarında 2 hastada alopesi ve kutanöz atrofi gözlemlemişler.…”

“…Yine steroid ile yapılan GON bloklarının özellikle küme tipi başağrısı ve tekrarlayan migrenlerde efektif olduğu yapılan çalışmalarda gösterilmiştir. [14,16] Çalışmamızda kısıtlayıcı bazı yönler vardı. Çalışmada kontrol grubunun olmaması bir dezavantajdır.…”

New and Emerging Treatments for Migraine

“…Several techniques to perform occipital nerve blocks exist, and they all appear effective [15]. However, there is a lack of controlled trials to assess its therapeutic benefits in treating migraines; most of them being small and uncontrolled [16,17]. For example, a study of 97 patients with migraine and 87 with post-traumatic headache who had GONB with a combination of lidocaine and methylprednisolone showed a significant improvement in 54% of migraineurs for up to 6 months [17].…”