Ultrasound-Guided Greater Occipital Nerve Block: An Efficient Technique in Chronic Refractory Migraine Without Aura?

Abstract

Background: The effectiveness of greater occipital nerve block (GONB) in patients with primary headache syndromes is controversial. Few studies have been evaluated the usefulness of GONB in patients with migraine without aura (MWOA). Objective: To compare the effectiveness of ultrasound-guided GONB using bupivacaine 0.5% and placebo on clinical improvement in patients with refractory MWOA in a randomized, doubleblinded clinical trial. Study Design: A prospective, randomized, placebo-controlled, double-blind pilot trial. Setting: Physical medicine and rehabilitation and neurology departments of a University Hospital. Methods: Thirty-two patients with a diagnosis of MWOA according to the International Classification of Headache Disorders-II criteria were included in the study. Twenty-three patients (2 men, 21 women) completed the study. They were randomly assigned to receive either GONB with local anesthetic (bupivacaine 0.5% 1.5 mL) or greater occipital nerve (GON) injection with normal saline (0.9% 1.5 mL). Ultrasound-guided GONB was performed to more accurately locate the nerve. All procedures were performed using a 7 – 13 MHz high-resolution linear ultrasound transducer. The treatment group was comprised of 11 patients and the placebo group was comprised of 12 patients. The primary outcome measure was the change in the headache severity score during the one-month post-intervention period. Headache severity was assessed with a visual analogue scale (VAS) from 0 (no pain) to 10 (intense pain). Results: In both groups, a decrease in headache intensity on the injection side was observed during the first post-injection week and continued until the second week. After the second week, the improvement continued in the treatment group, and the VAS score reached 0.97 at the end of the fourth week. In the placebo group after the second week, the VAS values increased again and nearly reached the pre-injection levels. The decrease in the monthly average pain intensity score on the injected side was statistically significant in the treatment group (P = 0.003), but not in the placebo group (P = 0.110). No statistically significant difference in the monthly average pain intensity score was observed on the uninjected side in either group (treatment group, P = 0.994; placebo group, P = 0.987). No serious side effect was observed after the treatment in either group. Only one patient had a self-limited vaso-vagal syncope during the procedure. Limitations: This trial included a relatively small sample. This may have been the result of the inclusion of only those patients who correctly completed their pain diaries. Another major limitation is the short follow-up duration. Patients were followed for one month after the injection, thus relatively long-term effects of the injection have not been observed. Conclusions: Ultrasound guided GONB with 1.5 mL of 0.5% bupivacaine for the treatment of migraine patients is a safe, simple, and effective technique without severe adverse effects. To increase the effectiveness of the injection, and to implement the isolated GONB, ultrasonography guidance could be suggested. Key words: Migraine, greater occipital nerve, occipital nerve block, ultrasound-guided

Effects of cranial nerve blockage in patients with chronic migraine resistant to first-line treatment

“…In some studies, nerve blocks were generally performed with bupivacaine, lidocaine, or both. The doses also differed, but an injection of 1.5 ml of 0.5% bupivacaine has been effective in previous studies [12,13,18]. The GON block was also effective in a study that used a 1 ml injection of 2% lidocaine [19].…”

The Potential Roles of Cervical Plexus Abnormalities in Occipital Neuralgia: An Anatomic Variant Explored

“…This result may be due to a more accurate injection of the nerves, which has been the subject of increased research interest, but also the use of a smaller quantity of anesthetic in these procedures [ 18 ]. An ultrasound-guided GON blockade at the level of the superior nuchal line has shown to be successful, resulting in improved pain scores compared to non-guided injections [ 18 , 21 , 22 , 23 ]. Injection at the C2 spinal nerve root, a more proximal location near the point of compression, may also result in an improved analgesic effect [ 18 ].…”

Peripheral Nerve Blocks for Postdural Puncture Headache: A New Solution for an Old Problem?

“…The classical landmark technique was used for GONB, except in Akyol et al (28), and LONB. However, the ultrasound guided technique is more target specific and it should be preferred (53). Lidocaine, levobupivacaine, bupivacaine, or ropivacaine were the local anesthetics of choice.…”