Headache Relief with a Nerve Block

Try this technique to get under migraine’s nerves.

Current estimates indicate that over one million patients visit the ED annually for acute migraines [1]. Not only are these attacks debilitating in the short-term, they have long-term effects on overall quality of life. The management of migraines is complicated by a wide range of analgesic regimens, none of which has proven consistent superiority over the others. Over 20 different migraine medications are currently being used and yet less than 25% of patients achieve sustained (>48h) headache relief, indicating that we still fall short of optimal management [2]. Additionally, many of the analgesic options we currently use contain adverse side effects such as nausea, dizziness, restlessness, akathisia and drowsiness. What we need is an analgesic regimen that is not only quick and efficacious, but contains minimal side effects to return the patient to their baseline quality of life.

This article is this first of a two-part review of migraine management within the emergency setting. Part one focuses on recent research highlighting the utilization of the greater occipital nerve block (GONB) for migraines in the emergency setting. In part two, we will focus on a step-wise approach to effective migraine management in the emergency setting.

ADVERTISEMENT

‘Migraine’ is one of the more commonly misused diagnoses used to label patients with headaches in the emergency room. Migraine is a clinical disorder that lacks definitive laboratory or neuroimaging findings. The International Headache Society (IHS) defines migraines as recurrent headaches (at least five life-time headaches), not associated with another disease pathology, lasting 4 to 72 hours with at least 2 of the following characteristics: unilateral location, pulsating quality, moderate to severe intensity or aggravated by physical activity [3]. Additionally, the diagnosis of migraine must include either photophobia/phonophobia or nausea/vomiting [3]. Though migraine is not synonymous with ‘severe headache,’ patients with severe headache often respond to a similar analgesic regimen and both can be addressed with a similar analgesic regimen. Unfortunately, a migraine is a relatively debilitating form of headache, typically resistant to oral medications used for mild/moderate headache pain such as acetaminophen and ibuprofen.

Recently, a long-anticipated research trial on ED migraine treatment came out of Bronx, NY investigating the utilization of greater occipital nerve blocks (GONB) in the ED setting for the treatment of refractory migraines (Friedman, 2018). Nerve blocks have been used for migraines for years, though less so in the emergency setting [4, 5]. One of the targeted nerves associated with migraines is the greater occipital nerve (GON), the rationale being the proximity and convergence of the GON neurons, which supply cutaneous sensory innervation to the posterior scalp – with the trigeminal nerve fibers that have been implicated in migraine flares [6, 7]. This convergence pattern also accounts for the location of pain distribution with migraines, which often includes both anterior and posterior regions of the head/upper neck.

In this randomized, sham-controlled clinical research trial, patients with acute, moderate or severe migraines who failed first-line therapy (metoclopramide) were randomized to receive either the treatment: 3 cc 0.5% bupivacaine injected bilaterally (6 cc total) over the greater occipital nerve or the sham control: 0.5 cc 0.5% bupivacaine injected bilaterally (1cc total) intradermally into the posterior scalp (overlying the greater occipital nerve). Of the 76 patients screened, the patients were predominantly women (80-90%), averaging 35-40 years old.

ADVERTISEMENT

Primary outcome of complete headache relief at 30 minutes was seen in 0% of the sham group versus 31% of the GONB grouping (p=0.035). Secondary outcome of sustained headache relief (defined as mild/no headache at 1 hour and at 48 hour follow up) was 0% in the sham group and only 23% in the GONB group (p=.087). [Note:  30 minutes was chosen as the timeframe because the researchers felt it unlikely that a patient would progress from moderate or severe migraine to complete headache freedom within 30 minutes spontaneously and without intervention]. Overall, approximately 4/10 participants in each group said they would not want to receive this treatment again (presumably due to pain with injection though this was not elicited).

Unfortunately, due to slow enrollment, the study was cut short and the full sample size was not achieved resulting in an underpowered study. Nevertheless, in the midst of the ‘opioid epidemic’ and the ever-evolving search for non-opioid analgesic alternatives in the ED, nerve blocks offer an effective alternative.  This was a small study, but the results are promising and the technique is simple to learn (see below). Additionally, a recently published prospective randomized control trial provided further support for the GONB showing it to be as effective as a traditional migraine regimen (dexketoprofen + metoclopramide) and superior to placebo in the ED setting [8]. Many will fairly argue whether medication is even needed and if saline or dry needling alone would result in migraine improvement. Until research proves otherwise, consider a bilateral greater occipital nerve block as a feasible alternative in your analgesic armamentarium for migraine management.

Performing the GONB can be completed using landmark localization. The following three-step landmark technique can be used to identify the greater occipital nerve on each side of the scalp [27]:

ADVERTISEMENT

1 – Place index finger on the occipital protuberance

2 – Place thumb on the mastoid process (either right or left side)

3 – Measure ⅓ the distance between two points extending from the occipital protuberance.

This is the approximate location of the greater occipital nerve as it extends up from its exit from the semispinalis capitus muscle at approximately the C1/C2 position (this is often noted as the point of maximal tenderness).

ADVERTISEMENT

Once identified,  3–5 cc of 1% to 2% lidocaine or 2–4 cc of 0.25% to 0.5% bupivacaine is injected using a 23-gauge needle to infiltrate the GON [6]. The optimal injection involves a “fanning technique” in which 1 cc of anesthetic is injected immediately adjacent to the GON, 1 cc medial to the GON, and 1 cc lateral to the GON for maximal infiltration. The “fanning technique” can be repeated bilaterally to cover both left and right GON [23, 24].

So where do nerve blocks fit in to a step-wise approach to migraine management? Check back next month for part two of this review of migraine management in the emergency setting.

References:

1. Friedman, B.W., et al., Current management of migraine in US emergency departments: an analysis of the National Hospital Ambulatory Medical Care Survey. Cephalalgia, 2015. 35(4): p. 301-9.
2. Friedman, B.W., et al., Recurrence of primary headache disorders after emergency department discharge: frequency and predictors of poor pain and functional outcomes. Ann Emerg Med, 2008. 52(6): p. 696-704.
3. International Headache Society Classification ICHD-3: Migraines Without Aura. 2018 [cited 2018; Available from: https://www.ichd-3.org/1-migraine/1-1-migraine-without-aura/.
4. Gawel, M.J. and P.J. Rothbart, Occipital nerve block in the management of headache and cervical pain. Cephalalgia, 1992. 12(1): p. 9-13.
5. Caputi, C.A. and V. Firetto, Therapeutic blockade of greater occipital and supraorbital nerves in migraine patients. Headache, 1997. 37(3): p. 174-9.
6. Ashkenazi, A. and M. Levin, Greater occipital nerve block for migraine and other headaches: is it useful? Curr Pain Headache Rep, 2007. 11(3): p. 231-5.
7. Bartsch, T. and P.J. Goadsby, Stimulation of the greater occipital nerve induces increased central excitability of dural afferent input. Brain, 2002. 125(Pt 7): p. 1496-509.
8. Korucu, O., et al., The effectiveness of greater occipital nerve blockade in treating acute migraine-related headaches in emergency departments. Acta Neurol Scand, 2018. 138(3): p. 212-218.
9. Friedman, B.W., et al., Randomized study of IV prochlorperazine plus diphenhydramine vs IV hydromorphone for migraine. Neurology, 2017. 89(20): p. 2075-2082.
10. Orr, S.L., et al., Management of Adults With Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies. Headache, 2016. 56(6): p. 911-40.
11. Friedman, B.W., Managing Migraine. Ann Emerg Med, 2017. 69(2): p. 202-207.
12. Friedman, B.W., et al., Randomized trial of IV valproate vs metoclopramide vs ketorolac for acute migraine. Neurology, 2014. 82(11): p. 976-83.
13. Gaffigan, M.E., et al., A Randomized Controlled Trial of Intravenous Haloperidol vs. Intravenous Metoclopramide for Acute Migraine Therapy in the Emergency Department. J Emerg Med, 2015. 49(3): p. 326-34.
14. D’Souza, R.S., et al., Effects of prophylactic anticholinergic medications to decrease extrapyramidal side effects in patients taking acute antiemetic drugs: a systematic review and meta-analysis. Emerg Med J, 2018. 35(5): p. 325-331.
15. Vinson, D.R. and D.L. Drotts, Diphenhydramine for the prevention of akathisia induced by prochlorperazine: a randomized, controlled trial. Ann Emerg Med, 2001. 37(2): p. 125-31.
16. Cameron, J.D., P.L. Lane, and M. Speechley, Intravenous chlorpromazine vs intravenous metoclopramide in acute migraine headache. Acad Emerg Med, 1995. 2(7): p. 597-602.
17. Bigal, M.E., C.A. Bordini, and J.G. Speciali, Intravenous chlorpromazine in the emergency department treatment of migraines: a randomized controlled trial. J Emerg Med, 2002. 23(2): p. 141-8.
18. Balbin, J.E., et al., Intravenous fluids for migraine: a post hoc analysis of clinical trial data. Am J Emerg Med, 2016. 34(4): p. 713-6.
19. Colman, I., et al., Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ, 2008. 336(7657): p. 1359-61.
20. Delavar Kasmaei, H., et al., Ketorolac versus Magnesium Sulfate in Migraine Headache Pain Management; a Preliminary Study. Emerg (Tehran), 2017. 5(1): p. e2.
21. Bigal, M.E., et al., Intravenous magnesium sulphate in the acute treatment of migraine without aura and migraine with aura. A randomized, double-blind, placebo-controlled study. Cephalalgia, 2002. 22(5): p. 345-53.
22. Diener, H.C., Efficacy and safety of intravenous acetylsalicylic acid lysinate compared to subcutaneous sumatriptan and parenteral placebo in the acute treatment of migraine. A double-blind, double-dummy, randomized, multicenter, parallel group study. The ASASUMAMIG Study Group. Cephalalgia, 1999. 19(6): p. 581-8; discussion 542.
23. Taneri, Z. and M. Petersen-Braun, [Double blind study of intravenous aspirin vs placebo in the treatment of acute migraine attacks.]. Schmerz, 1995. 9(3): p. 124-9.
24. Friedman, B.W., et al., A Randomized, Sham-Controlled Trial of Bilateral Greater Occipital Nerve Blocks With Bupivacaine for Acute Migraine Patients Refractory to Standard Emergency Department Treatment With Metoclopramide. Headache, 2018.
25. Moshtaghion, H., et al., The Efficacy of Propofol vs. Subcutaneous Sumatriptan for Treatment of Acute Migraine Headaches in the Emergency Department: A Double-Blinded Clinical Trial. Pain Pract, 2015. 15(8): p. 701-5.
26. Khan, S., J. Schoenen, and M. Ashina, Sphenopalatine ganglion neuromodulation in migraine: what is the rationale? Cephalalgia, 2014. 34(5): p. 382-91.
27. Bird, N., E.A. MacGregor, and M.I. Wilkinson, Ice cream headache–site, duration, and relationship to migraine. Headache, 1992. 32(1): p. 35-8.
28. Cady, R., et al., A double-blind, placebo-controlled study of repetitive transnasal sphenopalatine ganglion blockade with tx360((R)) as acute treatment for chronic migraine. Headache, 2015. 55(1): p. 101-16.
29. Schaffer, J.T., et al., Noninvasive sphenopalatine ganglion block for acute headache in the emergency department: a randomized placebo-controlled trial. Ann Emerg Med, 2015. 65(5): p. 503-10.
30. Maizels, M., et al., Intranasal lidocaine for treatment of migraine: a randomized, double-blind, controlled trial. JAMA, 1996. 276(4): p. 319-21.