Occipital Nerve Block Research Articles

Bilateral Greater Occipital Nerve Block for Preventing the OnabotulinumtoxinA Wear-off Phenomenon in the Treatment of Chronic Migraine: A Case Series of 12 Patients

Purpose: OnabotulinumtoxinA is widely used to treat chronic migraines; however, the wear-off phenomenon before the next scheduled dose has emerged as a challenge. This study suggests a new strategy for preventing the wear-off phenomenon using bilateral greater occipital nerve block. Methods: We conducted a retrospective review of patients diagnosed with chronic migraine who were treated with onabotulinumtoxinA and bilateral greater occipital nerve block at St. Vincent Hospital from January 2023 to December 2023. Twelve chronic migraine patients with a history of the wear-off phenomenon received a greater occipital nerve block 8 weeks after the initial onabotulinumtoxinA injection for two sessions. Responses to treatment were evaluated with regular follow-ups and daily headache diaries. Results: All patients who had previously experienced the wear-off phenomenon with conventional onabotulinumtoxinA treatment did not experience the wear-off phenomenon during two sessions with an additional greater occipital nerve block administered 8 weeks after each onabolulinumtoxinA injection. Conclusion: Bilateral greater occipital nerve block administered 8 weeks after the initial onabotulinumtoxinA injection effectively prevents the wear-off phenomenon, enabling sustained therapeutic benefits in chronic migraine patients. Further research is needed to confirm these findings in larger cohorts.

A novel technique to identify and thermally ablate the greater occipital nerve for patients with occipital neuralgia: a retrospective study with cadaveric and ex-vivo validation.

This manuscript presents the challenges of treating various forms of headaches and the potential of interventional techniques targeting the greater occipital nerve (GON) to alleviate the burden on patients. Occipital neuralgia, characterized by stabbing or shooting pain in the base of the skull, is often associated with primary, cervicogenic, or migraine headaches. While occipital nerve blocks offer temporary relief, durable treatment options are limited. Pulsed radiofrequency (PRF) and thermal radiofrequency ablation (TRFA) have shown promise as minimally invasive procedures for long-term treatment. However, GON is not easily identified using ultrasound or fluoroscopic analysis; thereby, minimizing success of proper ablation. Here, the authors provide a percutaneous strategy to localize the GON and maximize lesion performance. We intend to provide an ex-vivo description of staggered bipolar radiofrequency (RF) lesioning and include the use of staggered bipolar lesioning of the GON and stimulation of the semispinalis capitis. We also analyzed the effectiveness and side effects from this ablation, retrospectively. Patients with chronic refractory GON neuralgia were selected for GON TRFA. A novel double needle technique of sequential electrical stimulation was used to localize the GON and approximate needle to nerve distance. Once the needles were positioned adjacent to the GON, TRFA was performed using a bipolar staggered technique. Twenty-two patients with GON were treated with TRFA using a novel double needle technique. Seventy-two percent of these patients reported greater than 50% pain relief at both 1 and 6 months following the procedure. The results of our ex-vivo study demonstrate that performing TRFA using the parallel needle bipolar approach separated 8 mm apart produced the most desirable lesion dimensions that may correlate with effective ablation of the GON. This study demonstrates a new localization and ablation technique to treat refractory headaches. However, larger studies are needed to confirm our findings.

Influence of greater occipital nerve block on the relief of acute migraine: A meta-analysis.

Greater occipital nerve (GON) block may help relieve acute migraine, and this meta-analysis aimed to investigate the influence of GON block on pain relief of acute migraine. We systematically searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases, and included randomized controlled trials (RCTs) assessing the efficacy of GON block for acute migraine. Meta-analysis was performed using the random-effect model regardless of the heterogeneity. Four RCTs and 224 patients were included in the meta-analysis. Compared with control intervention in acute migraine, GON block intervention could significantly reduce pain scores at 45 to 60 minutes (MD = -2.31; 95% CI = -3.08 to -1.53; P < .00001) and pain scores at 30 minutes (MD = -1.95; 95% CI = -2.61 to -1.29; P < .00001), but demonstrated no impact on pain scores at 0 to 15 minutes (MD = -0.46; 95% CI = -1.00 to 0.08; P = .09), sustained headache relief (OR = 1.46; 95% CI = 0.06-36.66; P = .82) or rescue medication (OR = 0.32; 95% CI = 0.01-19.16; P = .59). GON block intervention may be able to alleviate pain intensity for acute migraine patients.

When Should Headache Specialists Hold a Needle? The Role of Botulinum Toxin Injections and Occipital Nerve Blocks

When Should Headache Specialists Hold a Needle? The Role of Botulinum Toxin Injections and Occipital Nerve Blocks

Post Dural Puncture Headache After Spinal Cord Stimulator Lead Insertion Successfully Treated with Occipital Nerve Blocks

Post Dural Puncture Headache After Spinal Cord Stimulator Lead Insertion Successfully Treated with Occipital Nerve Blocks

ANODYNE study: A double-blind randomized trial of greater occipital nerve block of methylprednisolone and lignocaine versus placebo as a transitional preventive treatment for episodic cluster headache.

There is inadequate evidence of the efficacy of greater occipital nerve block (GONB) for the preventive treatment of cluster headaches. We assessed the efficacy and tolerability of GONB injections as a transitional preventive treatment for episodic cluster headaches (ECH). This randomized, double-blind, placebo-controlled, parallel-group trial conducted at GB Pant Institute of Postgraduate Medical Education and Research, New Delhi, India, included ECH patients diagnosed by ICHD-3 criteria, aged 18-65, with one or more attacks per 24 h for seven days before randomization (baseline). ECH patients were either not on preventive medications or on stable doses for at least three months. ECH patients were randomized to receive active GONB (2 ml methylprednisolone (80 mg) and 2 ml lignocaine (2%)) and placebo (4 ml saline injections). Before giving GONB, lignocaine jelly was applied topically to mask the effect of numbness following the GONB. The primary efficacy endpoint was the mean change in weekly attack frequency from baseline to Week 4. Efficacy analyses were performed in a modified intention-to-treat population that included all patients who received at least one injection of GONB and had a follow-up for one week following GONB. The safety analysis included treatment-emergent adverse effects (TEAE) in all patients who received at least one dose of investigational product. The trial was registered with the Clinical Trials Registry of India (CTRI/2021/21/038397). Forty ECH patients were randomized between December 2021 and January 2023. Thirty-nine patients (19 in the active and 20 in the placebo groups) were available for efficacy analysis. The change in weekly attack frequency from baseline to Week 4 was -11.1 (95% CI: -8.5 to -4.4) for the active group compared to -7.7 (95% CI: -11.8 to -9.8) for placebo (mean difference -3.4 (95% CI: -5.2 to -1.7, p < 0.001). We noted TEAE in 18 (90%) of 20 patients who received the active drug and in 18 (90%) of 20 patients who received a placebo (p = 0.38). The common TEAE were local site bleeding and pain, which were mild and transient. No serious adverse events were reported. This study found that GONB with methylprednisolone and lignocaine significantly reduced the weekly attack frequency from baseline to Week 1 through Week 4 in ECH patients compared to a placebo. GONB was well tolerated.

Excision of Giant Occipital-Lateral Neck Lipoma with Ultrasound Guided Superficial Cervical Plexus Block Combined with Greater Occipital Nerve Block

Excision of Giant Occipital-Lateral Neck Lipoma with Ultrasound Guided Superficial Cervical Plexus Block Combined with Greater Occipital Nerve Block

Effectiveness of combining greater occipital nerve block and pulsed radiofrequency treatment in patients with chronic migraine: a double-blind, randomized controlled trial

BackgroundPulsed radiofrequency (PRF) treatment targeting the greater occipital nerve (GON) has shown efficacy in treating various conditions. This double-blind, randomized controlled study aimed to evaluate the effects of combining PRF therapy with GON block (GONB) therapy in patients with chronic migraine.MethodsThe study consisted of two groups: GONB and GONB + PRF, each comprising 16 patients with chronic migraine. Using 0.5-Hz sensorial stimulation, a 5-cm-long radiofrequency needle was inserted under ultrasound guidance in both groups. Subsequently, all patients received a GONB by administering 2 mL of 0.25% bupivacaine. In the GONB + PRF group, patients underwent 4 min of PRF at 42℃, whereas the GONB group did not receive any PRF treatment. Follow-up examinations were performed at 1, 2, 3 and 6 months after the procedure to evaluate the frequency and severity of migraine attacks, number of headache days, and analgesic consumption.ResultsIn the GONB + PRF group, the visual analog scale (VAS) score, number of migraine attacks, number of headache days, and analgesic consumption were significantly lower compared to the GONB group (P < 0.05). Significant decreases (60%) in mean VAS scores, number of migraine attacks, number of headache days, and consumption of analgesic medications were observed in the GONB + PRF group at the 1-, 2-, 3-, and 6-month follow-ups compared with the pre-treatment period (P < 0.05).ConclusionsThe combination of GONB and PRF presents a promising new treatment option for patients with chronic migraine. This approach has demonstrated efficacy in minimizing analgesic use, decreasing the frequency of migraine attacks, reducing the number of headache days and decreasing the severity of migraine attacks.Trial RegistrationNCT05464212.

Comparison of two methods of greater occipital nerve block in patients with chronic migraine: ultrasound-guided and landmark-based techniques

BackgroundMigraine is a primary headache defined as moderate-to-severe pain lasting 4 to 72 h, ranking 2nd among the disabling conditions for both genders regardless of the age and the greater occipital nerve (GON) block has been reported as an efficient treatment method for migraine. The present study aims to evaluate and compare the efficiency of the two methods of GON block, i.e., the ultrasound (US)-guided technique and the landmark-based technique.MethodHaving a prospective and randomized design, the study assigned the patients with chronic migraine into two groups after which a neurologist performed landmark-based GON block in the first group while an algologist performed US-guided GON block in the second group. During the 3-month follow-up period, the number of days with pain, the duration of pain, the number of analgesic drugs taken in a month, and Visual Analogue Scale (VAS) scores were compared with the values ​​before treatment and at the 1st week, 1st month, and 3rd month after treatment.ResultsUS-guided GON block group included 34 patients while there were 32 patients in the landmark-based GON block group. US-guided GON block group showed significantly reduced VAS scores and frequency of attacks compared to the landmark-based GON block group at Month 1 after the procedure. After a 3-month follow-up period of the two groups, the frequency of attacks, analgesic intake and the duration of attacks were lower in both groups compared to the baseline. At 3-month follow-up, the mean of VAS scores decreased from 9,47 ± 2,69 to 4,67 ± 1,9 in US-guided GON block group and from 9,46 ± 0,98 to 7 ± 2,5 in the landmark-based GON block group.ConclusionIt was determined that both US-guided and landmark-based GON block were efficient techniques in patients with chronic migraine. US-guided GON block technique resulted in lower VAS scores, shorter durations of pain, lower frequencies of attack, and lower intake of analgesics compared to the landmark-based GON block technique.

11. Cervicogenic headache and occipital neuralgia.

Cervicogenic headache (CEH) and occipital neuralgia (ON) are headaches originating in the occiput and that radiate to the vertex. Because of the intimate relationship between structures based in the occiput and those in the upper cervical region, there is significant overlap between the presentation of CEH and ON. Diagnosis starts with a headache history to assess for diagnostic criteria formulated by the International Headache Society. Physical examination evaluates range of motion of the neck and the presence of tender areas or pressure points. The literature for the diagnosis and treatment of CEH and ON was searched from 2015 through August 2022, retrieved, and summarized. Conservative treatment includes pain education and self-care, analgesic medication, physical therapy (such as reducing secondary muscle tension and improving posture), the use of TENS (transcutaneous electrical nerve stimulation), or a combination of the aforementioned treatments. Injection at various anatomical locations with local anesthetic with or without corticosteroids can provide pain relief for a short period. Deep cervical plexus block can result in improved pain for less than 6 months. In both CEH and ON, an occipital nerve block can provide important diagnostic information and improve pain in some patients, with PRF providing greater long-term pain control. Radiofrequency ablation of the cervical facet joints can result in improvement for over 1 year. Occipital nerve stimulation (ONS) should be considered for the treatment of refractory ON. The treatment of CEH preferentially consists of radiofrequency treatment of the facet joints, while for ON, pulsed radiofrequency of the occipital nerves is indicated. For refractory cases, ONS may be considered.

An anatomical analysis of the occipital nerve complex: an essential tool for the application of occipital nerve blocks

BackgroundOccipital nerve blocks are essential in diagnosing and treating headache disorders such as migraine, cervicogenic headache, occipital neuralgia, and cluster headache. In this study, we aimed to investigate the potential compression points of the greater occipital nerve (GON), third occipital nerve (TON), and lesser occipital nerve (LON) which are targeted to block in occipital nerve blocks and to develop a method to detect these points easily.MethodsTo identify potential compression points of the GON, TON, and LON, we dissected 43, 41, and 26 cadavers, respectively. A rigid, transparent tool divided into 1 × 1 cm sections was placed on the external occipital protuberance to measure the determined points. The cadaveric head was viewed from above, vertically, and the coordinates corresponding to each point were noted separately.ResultsSix, four, and one potential entrapment points were detected for the GON, TON, and LON, respectively. The distances of the point where the GON arose from the lower border of the obliquus capitis inferior muscle and the emerging point of the TON from the C2-C3 vertebrae to the posterior midline were statistically significant in terms of the sides (p = 0.040). Similarly, there was a statistical significance between genders for the distance of the point where the LON arose from the posterior edge of the sternocleidomastoid muscle to the posterior midline (p = 0.002).ConclusionsWe believe that with the method developed, the GON, TON, and LON compression points can be easily localized and blocked in diagnosing and treating patients experiencing headaches such as migraines, cervicogenic headaches, occipital neuralgia, and cluster headache.

Post-dural puncture headache treated with grater occipital nerve block

Introdution: post-dural puncture headache (PDPH) is an importante and relatively frequent complication after dural puncture. It is a intense pain that worsens when sitting or standing and improves when lying down. Epidural blood tamponade is the most effective treatment, but it is invasive. Objective is to demonstrate the results of greater occipital nerve (GON) block in the treatment of PDPH. Method: 3 patients after cesarean section with PDPH were evaluated. They agreed to GON blockade after failure of hydration, bed rest and analgesics. Blockade was performed bilaterally with 2 ml of lidocaine (20 mg/ml) and 2 ml of dexametasone (2 mg/ml). Results: analogic visual scale (AVS) before the procedure was 8 for the first patient, 8 for the second and 9 for the third respectively, with the patients sitting (average 8.3). After 2 hours of GON blockade, the AVS was 1, 2 and 2 respectively (average 1.6). After 24 hours, the AVS was 0, 1 and 1 (average 0.6). No side effects were reported. Conclusion: in the cases in question, GON blockade showed good efficacy in the treatment of PDPH. The procedure is simple and quite safe. Although epidural blood patching is the definitive treatment for PDPH, GON blockade is an option to be considered for the treatment of these patients.

Efficacy and safety of greater occipital nerve block with a small volume of lidocaine and methylprednisolone in tertiary headache center

Background: The greater occipital nerve block (GON-B) is used in clinical practice for treating different forms of headache. There is no standardized procedure to perform GON-B. This study evaluates the efficacy and feasibility of a low-volume GON-B protocol utilizing a pre-mixed solution of lidocaine (10 mg) and methylprednisolone (40 mg) across various headache disorders. Methods: This observational case series included patients receiving their first GON-B from November 2019 to February 2021. Participants were diagnosed with migraine, cluster headache, cervicogenic headache, or paroxysmal hemicrania. The primary outcome was the degree of response to the GON-B. Results: Thirty-nine patients with migraine underwent a first GON-B. Regarding headache frequency, 26% achieved substantial response and 33% partial response. For headache intensity, 26% reported substantial and 49% partial improvement. Migraine patients experienced a significant reduction in median monthly headache days from 25 to 13 (p=0.001) and in headache intensity from a median of 8 to 6 on the Numerical Rating Scale (NRS) scale (p&lt;0.001). Of the 27 patients receiving a second GON-B, 33% had a substantial response, 48% a partial response, and 19% no response. Results from subsequent sessions were consistent with these findings. Ten patients with cluster headache underwent GON-B, showing a significant reduction in pain intensity from a median NRS score of 10 to 5 (p=0.008). Two patients with cervicogenic headache showed a partial response to GON-B, with pain intensity decreasing from 8 to 6 and 8 to 7 over 30 monthly episodes. A patient with paroxysmal hemicrania received seven GON-B injections, reducing daily attacks from 30 to 10 and pain intensity from 7 to 6 on the NRS scale. Conclusions: These outcomes affirm GON-B potential in interrupting pain pathways, even at a low dose, in a wide range of headache disorders.

Radiographic Assessment and Clinical Outcomes of Conservative Management in Atlanto-Axial Osteoarthritis: A Study of 108 Patients

Abstract Background: Atlanto-axial osteoarthritis (AAOA) is a degenerative cervical spine disorder predominantly affecting the elderly. The patients typically present with cervico-occipital pain and restricted and painful neck rotations. The condition is primarily diagnosed with an open-mouth view radiograph, and conservative management is the mainstay of treatment. This study aimed to evaluate the effectiveness of conservative management and a novel technique of greater occipital nerve (GON) block in AAOA and assess the radiographic changes in facet angles and autofusion of the facet joints following conservative management. Materials and Methods: This study was conducted in patients with AAOA. Pre- and post-treatment visual analog scale (VAS) and neck disability index (NDI) scores were compared to evaluate clinical improvement following conservative treatment. Additionally, the radiographs were also assessed for changes in the facet angles observed in AAOA. Data analysis was performed using SPSS version 25.0 (IBM, Chicago, IL, USA). Statistical tests including paired t tests and correlation coefficients were used. Results: The atlanto-axial facet angle was significantly reduced on the affected side (P &lt; 0.001) compared to the unaffected side. GON block significantly improved VAS and NDI scores (P &lt; 0.001). Auto-fusion of the arthritic facet joint was observed in 15.47% of patients following conservative treatment. Conclusion: Conservative management is the mainstay of AAOA treatment, effectively alleviating pain and improving the quality of life in the affected individuals.

Anatomical Studies Evaluating Pediatric Regional Anesthesia: A Scoping Review

Background: Pediatric regional anesthesia has been driven by the gradual rise in the adoption of opioid-sparing strategies and the growing concern over the possible adverse effects of general anesthetics on neurodevelopment. Nonetheless, performing regional anesthesia studies in a pediatric population is challenging and accounts for the scarce evidence. This study aimed to review the scientific foundation of studies in cadavers to assess regional anesthesia techniques in children. Methods: We searched the following databases MEDLINE, EMBASE, and Web of Science. We included anatomical cadaver studies assessing peripheral nerve blocks in children. The core data collected from studies were included in tables and comprised block type, block evaluation, results, and conclusion. Results: The search identified 2409 studies, of which, 16 were anatomical studies on the pediatric population. The techniques evaluated were the erector spinae plane block, ilioinguinal/iliohypogastric nerve block, sciatic nerve block, maxillary nerve block, paravertebral block, femoral nerve block, radial nerve block, greater occipital nerve block, infraclavicular brachial plexus block, and infraorbital nerve block. Conclusion: Regional anesthesia techniques are commonly performed in children, but the lack of anatomical studies may result in reservations regarding the dispersion and absorption of local anesthetics. Further anatomical research on pediatric regional anesthesia may guide the practice.

The anatomical descriptive pattern of the greater occipital nerve in identified Brazilian cadavers and its clinical implications for scalp anesthesia and migraine treatment

Among the measures instituted for the treatment of migraine, the greater occipital nerve (GON) block is described as being an effective, safe, easy to perform and useful technique for the treatment of this condition. However, the measures used to block the GON vary, and there is a lack of information data about the Brazilian population. Therefore, a morphometric study was carried out on 22 identified cadavers, in which the distances were measured on both sides of the following anatomical points: EOP, MP, and GON with anatomical references of the nuchal ligament, Trapezius muscle aponeurosis and MSEC perforation. ANOVA was used for statistical analysis, with Tukey post-hoc and Eta Square (η2) for effect size. Significance was adopted when p ≤ 0.05. The ANOVA found a significant effect of ethnicity regarding the distances in the GON measurements of the EOP on the line between the EOP and MP – Left antimere; subsequent univariate analysis showed differences between white and oriental ethnicity (pTukey= 0.02); horizontal distance of the GON about the nuchal line – Right antimere; Subsequent univariate analysis showed differences between white and brown ethnicities (pTukey= 0.02); horizontal distance of the GON about the nuchal line – Left antimere. Subsequent univariate analyses showed differences between white and brown ethnicities (pTukey= 0.02). There are morphometric differences in some anatomical points used to block the GON when comparing the two antimeres, as well as in white, brown, and oriental ethnicities.

The effect of greater occipital nerve block on amplification of somatic symptoms and anxiety and depression levels in chronic migraine.

It is known that chronic migraine (CM) is often accompanied by anxiety, depression, and psychosomatic complaints. We designed this study with the assumption that greater occipital nerve (GON) block treatment could potentially improve not only pain symptoms but also psychosomatic complaints. This study aimed to evaluate the changes in the visual analog scale (VAS), somatosensory amplification scale (SSAS), beck depression ınventory (BDI), and beck anxiety ınventory (BAI) with GON block treatment in patients with CM. This study was conducted retrospectively on 164 patients with CM between December 2018 and January 2023. Patients underwent six sessions of GON block treatment at weeks 0, 1, 2, 3, 5, and 7. VAS, SSAS, BAI, and BDI scores; number of attacks per month (NAM); attack pain duration (APD); and monthly use of analgesics (UA) were compared before the start and at week 8 of GON block treatment. The mean age of the subjects was 38 ± 9years. Statistical analysis revealed that VAS, SSAS, BAI, and BDI scores; NAM; APD; and monthly UA were statistically significantly lower following GON block treatment than before GON block treatment (p < 0.001 each). GON block treatment was effective for pain and somatic complaints (amplification of physical symptoms), anxiety, and depressive symptoms accompanying CM in patients with CM.

Occipital Nerve Block Compared With Acetaminophen and Caffeine for Headache Treatment in Pregnancy

(Obstet Gynecol. 2023;142:1179–1188) Tension and migraine headaches affect a significant portion of individuals of reproductive age and are a common complaint during pregnancy. Unfortunately, headache treatment during pregnancy can be difficult because of the effect of some treatments on fetal health and a fear of masking secondary headaches that could be related to pregnancy complications such as pre-eclampsia. One treatment that has been established as effective in a nonobstetric population is occipital nerve block, which involves a subcutaneous injection of local anesthetic into the area surrounding the occipital nerves. The local anesthetics typically used are consistent with those used in epidural analgesia during labor and delivery, and thus are theoretically safe in pregnant individuals. This study was designed to assess the efficacy of occipital nerve block treatment for acute headache in pregnancy compared with standard care.

Randomized Controlled Trial of Lidocaine Occipital Nerve Blocks to Treat Status Migrainosus in Children/Adolescents (S22.009)

Randomized Controlled Trial of Lidocaine Occipital Nerve Blocks to Treat Status Migrainosus in Children/Adolescents (S22.009)

Excellent Response to Repeated Greater Occipital Nerve Blocks in a Patient with Short-Lasting Unilateral Neuralgiform Headache with Conjunctival Tearing.

Excellent Response to Repeated Greater Occipital Nerve Blocks in a Patient with Short-Lasting Unilateral Neuralgiform Headache with Conjunctival Tearing.