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Greater Occipital Nerve and Other Aesthetic Injections for Primary Headache Disorders
Young WB, Marmura M, et al.
Posted: September 2008
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
patientís 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.