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Occipital nerve block for headaches: a narrative review

  • William H. Arata1
  • Rajiv K. Midha1
  • Giustino Varrassi2,*,
  • Kelly Sala3
  • Michael J. Plessala3
  • Jared Brodtmann3
  • Kylie Dufrene4
  • Zachary Palowsky5
  • Patricia Griffin5
  • Shahab Ahmadzadeh5
  • Sahar Shekoohi5,*,
  • Alan D. Kaye6

1School of Medicine, St. George’s University, St. George, Grenada

2Paolo Procacci Foundation, 00193 Roma, Italy

3School of Medicine, Louisiana Health Sciences Center at New Orleans, New Orleans, LA 70112, USA

4School of Medicine, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA 71103, USA

5Department of Anesthesiology, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA 71103, USA

6Departments of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA 71103, USA

DOI: 10.22514/jofph.2024.010 Vol.38,Issue 2,June 2024 pp.1-10

Submitted: 08 February 2024 Accepted: 21 March 2024

Published: 12 June 2024

*Corresponding Author(s): Giustino Varrassi E-mail: g.varrassi@fondazioneprocacci.org
*Corresponding Author(s): Sahar Shekoohi E-mail: sahar.shekoohi@lsuhs.edu

Abstract

The occipital nerve block involves the injection of a local anesthetic and possibly a corticosteroid near the occipital nerves at the base of the skull and aims at providing relief from chronic headaches by temporarily numbing or reducing inflammation around the occipital nerves. It has proven to be efficacious in treating chronic headaches, especially those that are refractory to medication; it is both diagnostic and therapeutic with symptom abatement from weeks to months. Occipital nerve blocks can be utilized alone or with standard-of-care therapy for various other headache conditions, such as cluster headaches, episodic headaches or chronic migraines. This review aims to provide an analysis of the world literature on the role of occipital nerve block (ONBs) in the treatment of headaches, including the procedure, efficacy and safety of ONB, and to elucidate the current understanding of ONBs. ONBs demonstrate diagnostic and therapeutic benefits with symptom abatement for weeks to months. Outcomes are generally well tolerated, with minimal side effects associated mainly with the injection process, including numbness, tingling and local discomfort. Greater occipital nerve blocks are an efficacious procedure to treat chronic headache symptoms, and future research should include additional longitudinal follow-up results and interactions of ONBs with other headache treatments.


Keywords

Occipital nerve block; Greater occipital nerve block; Local anesthetic; Chronic headache; Migraine; Occipital neuralgia


Cite and Share

William H. Arata,Rajiv K. Midha,Giustino Varrassi,Kelly Sala,Michael J. Plessala,Jared Brodtmann,Kylie Dufrene,Zachary Palowsky,Patricia Griffin,Shahab Ahmadzadeh,Sahar Shekoohi,Alan D. Kaye. Occipital nerve block for headaches: a narrative review. Journal of Oral & Facial Pain and Headache. 2024. 38(2);1-10.

References

[1] Cornett EM, Carroll Turpin MA, Pinner A, Thakur P, Sekaran TSG, Siddaiah H, et al. Pharmacogenomics of pain management: the impact of specific biological polymorphisms on drugs and metabolism. Current Oncology Reports. 2020; 22: 18.

[2] Choi I, Jeon SR. Neuralgias of the head: occipital neuralgia. Journal of Korean Medical Science. 2016; 31: 479–488.

[3] Yucel A, Thach A, Kumar S, Loden C, Bensink M, Goldfarb N. Estimating the economic burden of migraine on US employers. The American Journal of Managed Care. 2020; 26: e403–e408.

[4] Afridi SK, Shields KG, Bhola R, Goadsby PJ. Greater occipital nerve injection in primary headache syndromes—prolonged effects from a single injection. Pain. 2006; 122: 126–129.

[5] Kemp WJ 3rd, Tubbs RS, Cohen-Gadol AA. The innervation of the scalp: a comprehensive review including anatomy, pathology, and neurosurgical correlates. Surgical Neurology International. 2011; 2: 178.

[6] Güvençer M, Akyer P, Sayhan S, Tetik S. The importance of the greater occipital nerve in the occipital and the suboccipital region for nerve blockade and surgical approaches—an anatomic study on cadavers. Clinical Neurology and Neurosurgery. 2011; 113: 289–294.

[7] Janis JE, Hatef DA, Ducic I, Reece EM, Hamawy AH, Becker S, et al. The anatomy of the greater occipital nerve: part II. compression point topography. Plastic and Reconstructive Surgery. 2010; 126: 1563–1572.

[8] Ducic I, Moriarty M, Al-Attar A. Anatomical variations of the occipital nerves: implications for the treatment of chronic headaches. Plastic and Reconstructive Surgery. 2009; 123: 859–863.

[9] Tubbs RS, Salter EG, Wellons JC, Blount JP, Oakes WJ. Landmarks for the identification of the cutaneous nerves of the occiput and nuchal regions. Clinical Anatomy. 2007; 20: 235–238.

[10] Lainé G, Jecko V, Wavasseur T, Gimbert E, Vignes JR, Liguoro D. Anatomy of the greater occipital nerve: implications in posterior fossa approaches. Surgical and Radiologic Anatomy. 2022; 44: 573–583.

[11] Cesmebasi A, Muhleman MA, Hulsberg P, Gielecki J, Matusz P, Tubbs RS, et al. Occipital neuralgia: anatomic considerations. Clinical Anatomy. 2015; 28: 101–108.

[12] Güneş M, Özeren E. Effectiveness of bilateral greater and lesser occipital nerve blocks in the prophylaxis of episodic migraine. Duzce Medical Journal. 2021; 23: 93–96.

[13] Tobin J, Flitman S. Occipital nerve blocks: when and what to inject? Headache: The Journal of Head and Face Pain. 2009; 49: 1521–1533.

[14] Chowdhury D, Mundra A. Role of greater occipital nerve block for preventive treatment of chronic migraine: a critical review. Cephalalgia Reports. 2020; 3: 2515816320964401.

[15] Velásquez-Rimachi V, Chachaima-Mar J, Cárdenas-Baltazar E, Loayza-Vidalon A, Morán-Mariños C, Pacheco-Barrios K, et al. Greater occipital nerve block for chronic migraine patients: a meta-analysis. Acta Neurologica Scandinavica. 2022; 146: 101–114.

[16] Tang Y, Kang J, Zhang Y, Zhang X. Influence of greater occipital nerve block on pain severity in migraine patients: a systematic review and meta-analysis. The American Journal of Emergency Medicine. 2017; 35: 1750–1754.

[17] Allen SM, Mookadam F, Cha SS, Freeman JA, Starling AJ, Mookadam M. Greater occipital nerve block for acute treatment of migraine headache: a large retrospective cohort study. Journal of the American Board of Family Medicine. 2018; 31: 211–218.

[18] Siddiqui F, Caplinger A. Efficacy of greater occipital nerve block with or without bupivacaine in chronic migraineurs (P01.089). Neurology. 2013; 80: P01–089.

[19] VanderHoek MD, Hoang HT, Goff B. Ultrasound-guided greater occipital nerve blocks and pulsed radiofrequency ablation for diagnosis and treatment of occipital neuralgia. Anesthesia and Pain Medicine. 2013; 3: 256–259.

[20] Fernandes L, Randall M MD FRCP, Idrovo L DMed FRCP. Peripheral nerve blocks for headache disorders. Practical Neurology. 2020; 23: practneurol-2020-002612.

[21] Walker KJ, McGrattan K, Aas-Eng K, Smith AF. Ultrasound guidance for peripheral nerve blockade. Cochrane Database of Systematic Reviews. 2009; CD006459.

[22] Nair AS, Kodisharapu PK, Anne P, Saifuddin MS, Asiel C, Rayani BK. Efficacy of bilateral greater occipital nerve block in postdural puncture headache: a narrative review. The Korean Journal of Pain. 2018; 31: 80–86.

[23] Narouze S. Occipital neuralgia diagnosis and treatment: the role of ultrasound. Headache: The Journal of Head and Face Pain. 2016; 56: 801–807.

[24] Shim JH, Ko SY, Bang MR, Jeon WJ, Cho SY, Yeom JH, et al. Ultrasound-guided greater occipital nerve block for patients with occipital headache and short term follow up. Korean Journal of Anesthesiology. 2011; 61: 50–54.

[25] Greher M, Moriggl B, Curatolo M, Kirchmair L, Eichenberger U. Sonographic visualization and ultrasound-guided blockade of the greater occipital nerve: a comparison of two selective techniques confirmed by anatomical dissection. British Journal of Anaesthesia. 2010; 104: 637–642.

[26] Kissoon NR, O’Brien TG, Bendel MA, Eldrige JS, Hagedorn JM, Mauck WD, et al. Comparative effectiveness of landmark-guided greater occipital nerve (GON) block at the superior nuchal line versus ultrasound-guided GON block at the level of C2: a randomized clinical trial (RCT). The Clinical Journal of Pain 2022; 38: 271–278.

[27] Pingree MJ, Sole JS, Oʼ Brien TG, Eldrige JS, Moeschler SM. Clinical efficacy of an ultrasound-guided greater occipital nerve block at the level of C2. Regional Anesthesia and Pain Medicine. 2017; 42: 99–104.

[28] Castillo-Álvarez F, Hernando de la Bárcena I, Marzo-Sola ME. Greater occipital nerve block in the treatment of headaches. Review of evidence. Medicina ClInica. 2023; 161: 113–118.

[29] Hernandez J, Molina E, Rodriguez A, Woodford S, Nguyen A, Parker G, et al. Headache disorders: differentiating primary and secondary etiologies. Journal of Integrative Neuroscience. 2024; 23: 43.

[30] Jensen R. Peripheral and central mechanisms in tension-type headache: an update. Cephalalgia. 2003; 23: 49–52.

[31] Ashina M. Migraine. New England Journal of Medicine. 2020; 383: 1866–1876.

[32] Charles A. Advances in the basic and clinical science of migraine. Annals of Neurology. 2009; 65: 491–498.

[33] Charles A. Vasodilation out of the picture as a cause of migraine headache. The Lancet Neurology. 2013; 12: 419–420.

[34] Cutrer F. Pathophysiology of migraine. Seminars in Neurology. 2006; 26: 171–180.

[35] Ashina M, Katsarava Z, Do TP, Buse DC, Pozo-Rosich P, Özge A, et al. Migraine: epidemiology and systems of care. The Lancet. 2021; 397: 1485–1495.

[36] Harriott AM, Orlova Y. Anatomy and physiology of headache. Seminars in Neurology. 2022; 42: 459–473.

[37] Barloese M, Lund N, Petersen A, Rasmussen M, Jennum P, Jensen R. Sleep and chronobiology in cluster headache. Cephalalgia. 2015; 35: 969–978.

[38] Ashkenazi A, Blumenfeld A, Napchan U, Narouze S, Grosberg B, Nett R, et al. Peripheral nerve blocks and trigger point injections in headache management—a systematic review and suggestions for future research. Headache: The Journal of Head and Face Pain. 2010; 50: 943–952.

[39] Bogduk N, Govind J. Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment. The Lancet Neurology. 2009; 8: 959–968.

[40] Naja ZM, El-Rajab M, Al-Tannir MA, Ziade FM, Tawfik OM. Occipital nerve blockade for cervicogenic headache: a double-blind randomized controlled clinical trial. Pain Practice. 2006; 6: 89–95.

[41] Nampiaparampil DE. Prevalence of chronic pain after traumatic brain injury. JAMA. 2008; 300: 711–719.

[42] Hecht JS. Occipital nerve blocks in postconcussive headaches: a retrospective review and report of ten patients. Journal of Head Trauma Rehabilitation. 2004; 19: 58–71.

[43] Ostrowski P, Bonczar M, Plutecki D, Kwiecińska M, Rams D, Dziedzic M, et al. The occipital artery: a meta-analysis of its anatomy with clinical correlations. Anatomical Science International. 2023; 98: 12–21.

[44] Chowdhury D, Tomar A, Deorari V, Duggal A, Krishnan A, Koul A. Greater occipital nerve blockade for the preventive treatment of chronic migraine: a randomized double-blind placebo-controlled study. Cephalalgia. 2023; 43: 3331024221143541.

[45] Chowdhury D, Mundra A, Datta D, Duggal A, Krishnan A, Koul A. Efficacy and tolerability of combination treatment of topiramate and greater occipital nerve block versus topiramate monotherapy for the preventive treatment of chronic migraine: a randomized controlled trial. Cephalalgia. 2022; 42: 859–871.

[46] Bushman ET, Blanchard CT, Cozzi GD, Davis AM, Harper L, Robbins LS, et al. Occipital nerve block compared with acetaminophen and caffeine for headache treatment in pregnancy: a randomized controlled trial. Obstetrics & Gynecology. 2023; 142: 1179–1188.

[47] Salem AM, Salem AE, Eldin AS, Hagras AM. Single or double bilateral greater occipital nerve blocks to manage headache after spinal obstetric anesthesia. Journal of Anesthesia and Intensive Care Medicine. 2019; 8: 555745.

[48] Gaiser RR. Postdural puncture headache. Anesthesiology Clinics. 2017; 35: 157–167.

[49] Malekian N, Bastani PB, Oveisgharan S, Nabaei G, Abdi S. Preventive effect of greater occipital nerve block on patients with episodic migraine: a randomized double-blind placebo-controlled clinical trial. Cephalalgia. 2022; 42: 481–489.

[50] Ricquart Wandaele A, Kastler A, Comte A, Hadjidekov G, Kechidi R, Helenon O, et al. CT-guided infiltration of greater occipital nerve for refractory craniofacial pain syndromes other than occipital neuralgia. Diagnostic and Interventional Imaging. 2020; 101: 643–648.

[51] Gaul C, Roguski J, Dresler T, Abbas H, Totzeck A, Görlinger K, et al. Efficacy and safety of a single occipital nerve blockade in episodic and chronic cluster headache: a prospective observational study. Cephalalgia. 2017; 37: 873–880.

[52] Flamer D, Alakkad H, Soneji N, Tumber P, Peng P, Kara J, et al. Comparison of two ultrasound-guided techniques for greater occipital nerve injections in chronic migraine: a double-blind, randomized, controlled trial. Regional Anesthesia & Pain Medicine. 2019; 44: 595–603.

[53] Guner D, Bilgin S. Efficacy of adding a distal level block to a C2 level greater occipital nerve block under ultrasound guidance in chronic migraine. Annals of Indian Academy of Neurology. 2023; 26: 513–519.

[54] Karaoğlan M, İnan LE. A comparison of the clinical efficacy of GON block at the C2 level and GON block at the classical distal occipital level in the treatment of migraine. Clinical Neurology and Neurosurgery. 2022; 215: 107190.

[55] Lavin PJ, Workman R. Cushing syndrome induced by serial occipital nerve blocks containing corticosteroids. Headache: The Journal of Head and Face Pain. 2001; 41: 902–904.

[56] Lanteri-Minet M. Economic burden and costs of chronic migraine. Current Pain and Headache Reports. 2014; 18: 385.

[57] Inan LE, Inan N, Unal-Artık HA, Atac C, Babaoglu G. Greater occipital nerve block in migraine prophylaxis: narrative review. Cephalalgia. 2019; 39: 908–920.

[58] Caponnetto V, Ornello R, Frattale I, Di Felice C, Pistoia F, Lancia L, et al. Efficacy and safety of greater occipital nerve block for the treatment of cervicogenic headache: a systematic review. Expert Review of Neurotherapeutics. 2021; 21: 591–597.

[59] Hasırcı Bayır BR. Greater occipital nerve block is an effective treatment method for primary headaches? Agriculture. 2021; 34: 47–53.

[60] Shauly O, Gould DJ, Sahai-Srivastava S, Patel KM. Greater occipital nerve block for the treatment of chronic migraine headaches: a systematic review and meta-analysis. Plastic and Reconstructive Surgery. 2019; 144: 943–952.

[61] Zhang H, Yang X, Lin Y, Chen L, Ye H. The efficacy of greater occipital nerve block for the treatment of migraine: a systematic review and meta-analysis. Clinical Neurology and Neurosurgery. 2018; 165: 129–133.

[62] Kir HH. Greater occipital nerve block in patients with primary headache and early term results. Cukurova Medical Journal. 2022; 47: 1730–1737.

[63] Voigt CL, Murphy MO. Occipital nerve blocks in the treatment of headaches: safety and efficacy. The Journal of Emergency Medicine. 2015; 48: 115–129.

[64] Akin Takmaz S, Ünal Kantekin C, Kaymak C, Başar H. Treatment of post-dural puncture headache with bilateral greater occipital nerve block. Headache: The Journal of Head and Face Pain. 2010; 50: 869–872.

[65] Patel R, Urits I, Orhurhu V, Orhurhu MS, Peck J, Ohuabunwa E, et al. A comprehensive update on the treatment and management of postdural puncture headache. Current Pain and Headache Reports. 2020; 24: 24.

[66] Friedman BW, Irizarry E, Williams A, Solorzano C, Zias E, Robbins MS, et al. A randomized, double-dummy, emergency department‐based study of greater occipital nerve block with bupivacaine vs intravenous metoclopramide for treatment of migraine. Headache: The Journal of Head and Face Pain. 2020; 60: 2380–2388.

[67] Cvetkovic VV, Icco RD, Do TP, Pellesi L, Ashina M, Hansen JM. Greater occipital nerve block with local anesthetics and corticosteroids in treatment-resistant chronic migraine. Headache Medicine. 2021; 12: 160–167.

[68] Govindappagari S, Grossman TB, Dayal AK, Grosberg BM, Vollbracht S, Robbins MS. Peripheral nerve blocks in the treatment of migraine in pregnancy. Obstetrics & Gynecology. 2014; 124: 1169–1174.

[69] Jensen RH. Tension-type headache—the normal and most prevalent headache. Headache. 2018; 58: 339–345.


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