Acute Treatment With Nerve Blocks

This transcript has been edited for clarity.

Acute treatment with nerve blocks is often used to manage a variety of headache disorders.^[1] Nerve blocks are effective by stopping the transmission of signals from a peripheral nerve, and they likely have a downstream effect on quieting central noise during a headache disorder. Peripheral nerve blocks can be a great way to treat an acute headache, because patients can come into the office when they’re not feeling well, get a nerve block, and feel much better that day. The trouble is that using this [therapy] every time one has a headache can be cumbersome. (To travel in [to the office/clinic] every single time they’re not feeling well just to receive a nerve block can be a bit of a problem.)

So, often in clinical practice, we’ll use nerve blocks to treat a headache cycle that’s been ongoing for several days. Most likely what we would see is an acute migraine status in which someone has had a migraine that’s lasted 2 to 3 days, has taken their standard medication, and they’re not feeling better. We might bring them into the office to do a peripheral nerve block.

There is some evidence that the use of a greater occipital nerve block during a migraine attack can stop the acute attack itself.^[2] This greater occipital block is performed using local anesthetic. A nerve block registry study of physicians from the procedural section of the special interest group of the American Headache Society revealed that most physicians studied used bupivacaine as the only component of their greater occipital block for migraine.^[3] There is also evidence that a greater occipital block can stop a cluster cycle, although there is not much evidence regarding the effect on an acute cluster attack.^[4] Some case series have been published showing that a greater occipital block can help posttraumatic headache^[5]and hemicrania continua,^[6] and it is sometimes used during the acute headache phase for both of these headache disorders.

Sphenopalatine ganglion blocks have been studied to treat acute headache in the emergency department.^[7] However, results using the Tx360 device did not provide evidence for effects that last more than the day.^[7,8] Sphenopalatine ganglion blocks have demonstrated effectiveness for post-dural headaches, and they can be used to acutely treat headaches following a lumbar puncture or headaches from receiving a spinal anesthetic during a procedure such as a cesarean section without using an epidural blood patch.^[9]

In summary, peripheral nerve block may be considered as an outpatient method to treat an acute headache attack that may not be responding to conventional treatment.

American Headache Society

Peripheral nerve blocks are generally safe and well-tolerated procedures for the acute and preventive treatment of various primary headache disorders that can be performed in an emergency or outpatient setting.

Greater occipital nerve (GON) injection is very effective in aborting an attack period in cluster headache. Take care to avoid intra-arterial injection. Palpating for the point of maximum tenderness may improve accuracy. Use a 3-mL or a 5-mL syringe with a 25‐, 27‐, or 30‐gauge, 0.5‐ or 1‐inch needle. Insert the needle to a depth of 3‐4 mm, then slightly withdraw the needle, pull the plunger to verify that the needle is not intravascular, then inject the solution in a single injection or use a fan‐like distribution. Lidocaine 1%-2% (10-20 mg/mL) and/or bupivacaine 0.25% to 0.5% (2.5-5 mg/mL) can be used. If a combination of these two drugs is used, the recommended volume ratio (lidocaine/bupivacaine) is 1:1-1:3. The volume of injection is 1.5-3 mL per nerve.
Another commonly targeted nerve is the lesser occipital nerve (LON). LON arises from the second cervical nerve, and sometimes from the third as part of the cervical plexus. It may be localized for injection by drawing the same line used to localize the GON, but by moving two thirds of the way laterally from the occipital protuberance. The drugs and technique of injection are similar to GON block. However, the volume of injection is 1-2 mL per nerve.
Trigeminal nerve blocks, which include supratrochlear nerve (STN), supraorbital nerve (SON), and the auriculotemporal nerve (ATN), are also performed. Pressure should be applied to avoid periorbital hematoma. Lidocaine 1%-2% (10-20 mg/mL) and/or bupivacaine 0.25% to 0.5% (2.5-5 mg/mL) can be used. If a combination of these two drugs is used, the recommended volume ratio (lidocaine/bupivacaine) is 1:1-1:3. Note that corticosteroids are not recommended for use in any trigeminal nerve territories.
STN block: Inject at the superomedial aspect of the orbit. Use a 1-mL syringe with a 30-gauge, 0.5-inch needle. Insert the needle at the medial aspect of the corrugator muscle, a fingerbreadth lateral to the procerus, to a depth of 3-4 mm. (Alternatively, identify the supraorbital ridge by palpation, insert the needle lateral to the ridge and then advance medially into the subcutaneous tissue.) After negative aspiration, inject the solution. The volume of injection is 0.2-1.0 mL per nerve.
SON block: Inject above the supraorbital notch. The drugs and volume of injection are similar to STN blocks. Use a 1-mL syringe with a 30-gauge, 0.5-inch needle. Insert the needle at the corrugator muscle, at the mid-pupillary line. (Alternatively, identify the supraorbital notch by palpation, at the superior margin of the orbit, mid-pupillary line. Advance the needle medially and at a slight angle to avoid entering the foramen.) After negative aspiration, inject the solution at a depth of 3-4 mm. Apply pressure to avoid periorbital hematoma. Alternatively, post STN block, redirect the needle laterally and inject.
ATN block: Inject just anterior to the tragus. The drugs used are the same as those for STN and SON nerve blocks; the volume of injection is 0.5-1.0 mL for the single injection at the proximal part of the nerve. If injecting the superior branches as well, use 0.25 mL for each additional injection. Palpate for the temporal artery along its course anterior to the tragus; inject anterior to it at a depth of 4-6 mm. Carefully confirm the needle is not intravascular by gentle negative aspiration before injecting. Additional injections may be performed more superiorly, at the temporal fossa, where the nerve has multiple branches. Alternatively, insert the needle at the posterior margin of the mandibular ramus, at a level just inferior to the tragus, and inject at a depth of 20 mm at this point.
Lidocaine carries a lower teratogenic risk in pregnancy than bupivacaine.
Reports have suggested that the use of corticosteroids in certain PNBs may be beneficial in the treatment of some headache disorders, but more research is needed.

Reviewed by Angeliki Vgontzas, MD

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Acute Treatment With Nerve Blocks

American Headache Society

American Headache Society

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Authors and Disclosures

Author(s)

Jessica Ailani, MD

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Guidelines Reviewer: Angeliki Vgontzas, MD

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