Abstract
Objective: We investigated the efficacy and tolerability of greater occipital nerve block with lidocaine plus betamethasone in adults with chronic migraine in whom two or more previous preventive treatments were unsuccessful.
 Methods: Ten participants were enrolled in a 24-weeks, randomized, double-blind, placebo-controlled, crossover trial conducted at a single tertiary headache center in Copenhagen (Denmark). After a 4-week run-in period, participants underwent treatment with bilateral greater occipital nerve block with lidocaine plus betamethasone (GONb) or lidocaine plus saline (placebo) with a 4-week interval wash-out phase between the 8-week crossover periods. The primary aim was to compare the number of migraine days during crossover periods after GONb or placebo. This trial is registered at ClinicalTrials.gov (NCT02686983).
 Results: This study was stopped before achieving the a priori sample size, due to a slow enrollment. Ten participants were recruited, completed the study and were included in the analyses. At the baseline, the mean number of monthly migraine days was 22.9 (range, 14-30). No difference between GONb and placebo on the reduction of monthly migraine days was observed (p = 0.147; 95% CI between 0.6 and 3.7 days). Adverse events were recorded in two patients after GONb, compared with three patients after placebo.
 Conclusions: GONb is not beneficial in patients with difficult-to-treat chronic migraine.
Highlights
Migraine is a prevalent and disabling disorder characterized by moderate to severe, throbbing headache and associated symptoms, including nausea/vomiting and hypersensitivity to light and sounds.1,2 Its chronic form (CM) is defined by the presence of at least fifteen headache days per month, of which at least eight days with the features of migraine.1 In patients with CM, a preventive treatment is recommended
We investigated the efficacy and tolerability of greater occipital nerve block performed with lidocaine plus betamethasone (GONb) or lidocaine plus saline in patients with CM in whom two or more previous preventative treatments were unsuccessful
Between April 2017 and August 2019, 80 patients were screened for eligibility and ten were enrolled in the study (Figure 1)
Summary
Migraine is a prevalent and disabling disorder characterized by moderate to severe, throbbing headache and associated symptoms, including nausea/vomiting and hypersensitivity to light and sounds. Its chronic form (CM) is defined by the presence of at least fifteen headache days per month, of which at least eight days with the features of migraine. In patients with CM, a preventive treatment is recommended. In patients with CM, a preventive treatment is recommended Pharmacological therapies such as antidepressants, antiepileptics, antihypertensives, botulinum toxin type A and monoclonal antibodies targeting the calcitonin gene-related peptide (CGRP) pathway are currently prescribed, but a variable clinical response between patients makes management challenging.. Greater occipital nerve block is a peripheral nerve block technique used for the treatment of headache disorders5with positive reports in occipital neuralgia, cluster headache, cervicogenic headache and migraine.. Greater occipital nerve block performed with local anesthetics (lidocaine or bupivacaine) was beneficial in several studies for migraine prophylaxis.. The addition of corticosteroids is still controversial due to scarce and heterogeneous studies. had previous treatment failure (efficacy, tolerability or both) with two or more pharmacological classes of the following migraine preventive medications: tricyclic antidepressants, antiepileptics, antihypertensives, and botulinum toxin type A Greater occipital nerve block is a peripheral nerve block technique used for the treatment of headache disorders5with positive reports in occipital neuralgia, cluster headache, cervicogenic headache and migraine. The mechanism of action has been suggested to involve peripheral modulation of the nociceptive transmission in the caudal trigeminal nucleus and upper cervical segments. Greater occipital nerve block performed with local anesthetics (lidocaine or bupivacaine) was beneficial in several studies for migraine prophylaxis. the addition of corticosteroids is still controversial due to scarce and heterogeneous studies. had previous treatment failure (efficacy, tolerability or both) with two or more pharmacological classes of the following migraine preventive medications: tricyclic antidepressants, antiepileptics, antihypertensives, and botulinum toxin type A
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