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Greater Occipital Nerve and Other Aesthetic Injections for Primary Headache Disorders
Young WB, Marmura M, et al.
Posted: September 2008  
Headache   2008;48:1122-1125

Over the last several years, it has become increasingly clear that greater occipital nerve block (GONB) is effective in treating several primary headache disorders including migraine and cluster headache. GONB has been traditionally used to diagnose and treat occipital neuralgia. However, the effect of the GONB in primary headache disorders undermines the GONB as a diagnostic tool, a feature that is part of the International Headache Society criteria for occipital neuralgia.

The Uses of GONB:   Studies have found GONB effective in migraine, cluster headache, and post-traumatic headache, and in 2 cases of hemiplegic migraine auras. Several studies have shown benefit from GONB in occipital neuralgia, although we suspect most of those patients were misdiagnosed. In one study GONB was ineffective in chronic tension-type headache, but in another study was beneficial in postconcussive headaches. The effects in migraine appear to last less than 60 days. The onset of the benefit occurs within 2 minutes of the onset of the anesthesia, and is accompanied by relief of trigeminal and extratrigeminal allodynia, and photophobia.

Potential Adverse Events:   Overall, GONB is extraordinarily safe. Injection site pain may occur and for 5 minutes dizziness and lightheadedness may occur. Reversible coma has been reported in patients with skull defects, presumably because of the anesthetic infiltrates to the meninges. The use of local steroids has been associated with alopecia and hypopigmentation. Sometimes, patients report asmuch as a few days of local tenderness after the injection.

Trigger, Tender Point, or Paraspinal Injections:   Mellick has reported benefits for 417 headache patients in the Emergency Department that were treated with injections into the paraspinal muscles at C7. He injected 1.5 mL of bupivacaine 2-3 cm lateral to the C7 spinous process. He found complete relief in 65% and partial relief in 20%. Our practice is to inject up to 8 cc of 0.05% bupivacaine mixed with 2% lidocaine on paraspinal, suboccipital, or trapezius tender points or trigger points based upon the patient’s pain and examination. When the trapezius is injected near the apex of the lung, we pinch the muscle to isolate the muscle and decrease the chance of a pneumothorax.

What to Inject:   Short- or long-lasting local anesthetics may be injected. The 2 most commonly used anesthetics include lidocaine, whose half-life is 1.5-2 hours and bupivacaine, whose half-life is 3.5 hours. Many injections mix the local anesthetic with an injectable steroid. In migraine, there is no short-term benefit to using steroids. However, the long-term benefit is unknown. On the other hand, rare long-term steroid complications have been reported. Steroid injections may be locally damaging and foreign bodies have been noted years after the steroid injections. In migraine, we prefer to not use injectable steroids and, if desired, follow the anesthetic injections with oral steroids. Although there is evidence for a beneficial effect of long- plus short-acting steroid injection in the GON without local anesthetic, we also do not use injectable steroids in cluster headache.