Occipital and trigeminal nerve blocks for migraine.

Abstract

This is a 53-year-old male seen for con-sultation due to headaches since high school, whichhave been almost daily for the past 20 years. Hedescribesathrobbingpainbehindthelefteye,withanintensity of 5-9/10 and posterior cervical pressure,occasionally associated with nausea and vomiting,but no light or sound sensitivity. He takes rizatriptan10 mg daily, and the headache is gone in about1 hour. Every couple of weeks, the headache recursand he takes another dose of rizatriptan. He takeshydrocodone 1-2 tablets every couple of weeks.Alcohol triggers his headaches. Sumatriptaninjections and baclofen did not help. He has triedtopiramate, amitriptyline, divalproex sodium,gabapentin, and propranolol for headache preven-tion,without help.He also tried onabotulinumtoxinAonce, without help. Chiropractic treatment did nothelp. He has not tried acupuncture. Magnetic reso-nance imaging of the brain with and without contrast,done3monthspreviously,wasnegative.Hehasapastmedical history of hyperlipidemia, treated with astatin. Neurological examination was normal. Therewas bilateral greater occipital nerve (GON) tender-ness. Bilateral greater occipital nerve block (GONB)was performed by injection of 3 mL of 1% lidocaine2 cm lateral and 2 cm inferior to the inion on eachside. For headache prevention, he was started onzonisamide 100 mg daily for 2 weeks and then 200 mgdaily. He was informed on the risk of medicationoveruseheadachewithfrequentuseofrizatriptan.Hewas seen in follow-up 2 months later. During the 2weeks after the occipital nerve blocks (ONBs), hehad one headache that was quickly relieved byrizatriptan.For the following 14 days,he experiencedheadaches once every other day, and thereafter hisdaily headache pattern resumed, with prompt reliefby rizatriptan.