Occipital nerve block for an acute migraine
Occipital nerve blocks can stop a migraine attack when other treatments fail. This is a relatively simple procedure (although not many physicians are trained in it), and it consists of an injection of lidocaine or a similar local anesthetic drug into an area at the back of the head on one or both sides. There are two branches of the nerve – greater and lesser occipital nerves and I usually inject both. The block can help even if the headache is not strictly localized to the back of the head. In some people headache returns after a few hours, once the effect of the local anesthetic wears off. However, a recent study presented at the American Academy of Neurology suggested that up to 60% of patients with an acute migraine may respond without return of the headache. Adding steroid medication to the local anesthetic does not seem to improve outcome. However, occipital nerve block with steroid medication (Depo-Medrol, Celestone, and other) is effective in aborting cluster headaches.
Obviously, occipital nerve block is not practical or necessary treatment for people who respond to oral or self-injected medications, but if these treatments fail such a block is an excellent option. However, even if other treatments fail, we usually start office treatment of severe migraines with intravenous magnesium, which is more effective than any other treatment in those 50% of patients who are magnesium deficient.
Occipital nerve blocks can be effective in stopping an acute migraine that does not respond to medications or to stop a prolonged migraine (status migraine) that responds to medications only temporarily. However, it does not have the lasting effect that Botox can have – Botox starts working after a couple of weeks and can provide relief for three months. An occipital nerve block works only until the next migraine comes or, if headaches are continuous, it may help for a few days. Ongoing research suggests that an occipital nerve stimulator, which is surgically implanted under the skin can help chronic migraines. We are also planning to start trials of a vagus nerve stimulator (made by ElectroCore), which is not implanted and requires no surgery, for the treatment of chronic migraines.
My Pain Management doctor is planning on an Occipital Nerve Block. My neurologist, who referred me to the PM, has already given me a session of botulinum toxin (20 or so injections into my forehead, back of my head, etc) to no effect. Is the Occipital Nerve block more efficacious than Botox?
PS
we met about 6 years ago, I spent a day with you learning botulinum toxin techniques.
Dr. Mauskop,
I have a question about differentiating Cervicogenic headache from other causes.
I am in process of assisting with a review on occipital nerve stim for journal of PMR.
I would be interested in your thoughts to help in determining inclusion criteria for the literature.
please contact me at
john_orsini@urmc.rochester.edu