Quick Fix For Headaches – Repeated Nerve Supraorbital, Infraorbital, and Occipital Nerve Blocks – and What To Do For The Very Bad

Series of 3 simple eyebrow, just below eye and bottom of skull posterior injections can give long-lasting relief of headaches. Now, just to get family doctors to pick up a syringe…

To start with, I will discuss the latest in a long series of articles finding benefit:

Eur Rev Med Pharmacol Sci. 2013 Jul;17(13):1778-81.
Supraorbital and infraorbital nerve blockade in migraine patients: results of 6-month clinical follow-up.
Ilhan Alp S, Alp R.
http://www.europeanreview.org/wp/wp-content/uploads/1778-1781.pdf

• 26 cases migraines
• Technique – using 1.5 ml lidocaine 1% – done thrree times – with 3 days in between each time

Supraorbital nerve blockade – 2.5 cm lateral to the midline towards the supraorbital foramen located on the upper border of the orbit immediately below the eyebrow with a 23-
25 gauge needle to receive 1.5 ml of 1% lidocaine. – I just inject horizontally across inner 1/2 of eye at eyebrow level.

Infraorbital –  Upper lip was lifted to guide the injector parallel to the long axis of the second premolar, from the point where the mucosa met the gingival  23-25 gauge needle was inserted towards the infraorbital foramen to inject 1.5 ml of 1% lidocaine. – I prefer skin injection -infraorbital foramin is 1-1.5 cm below orbital rim – orbital rim juts out to protect eye some. So if inject angled inferiorly, will encounter foramen in line with puil looking forward – do not need to go in foramen. see previous blog note for more description
http://painmuse.org/?p=2865

• Results:

This is a little more spectacular than an earlier study that took severe resistant cases :
Caputi, Claudio A., and Vincenzo Firetto.
Therapeutic blockade of greater occipital and supraorbital nerves in migraine patients.
Headache: The Journal of Head and Face Pain 37, no. 3 (1997): 174-179.
http://www.ncbi.nlm.nih.gov/pubmed/9100402

They only injected nerves that were tender.

Does that make your mouth water?

Previous review on subject got similar results:
Ashkenazi, Avi, 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 50.6 (2010): 943-952.
http://www.ncbi.nlm.nih.gov/pubmed/20487039

Note – if you look carefully at picture, there is a third nerve medially – the trochlear nerve. This can be irritated by eyestrain and such and causes tenderness to inner aspect of orbit. I inject 40 mg kenalog (triamcinolone) into it and get longlasting relief from that. – Here is a discussion of that:

Primary trochlear headache: A new cephalgia generated and modulated on the trochlear region
J. Yangüela, MD*; M. Sánchez-del-Rio, MD*; A. Bueno, MD*; A. Espinosa, MD;
P. Gili, MD*; N. Lopez-Ferrando, MD; F. Barriga, MD*; J.C. Nieto, MD; and J.A. Pareja, MD, PhD*
NEUROLOGY 2004;62:1134–1140  abstract here

It originates from the upper inner eye socket and radiates to temple and forehead

Tip-off is tenderness to upper inner eye socket that is worse on looking up:

It is injected thus:

• Patients were given a 1-mL injection (25G 0.5-inch needle) containing 3 mg of dexamethasone and 3 mg of methylprednisolone targeted to the symptomatic trochlea
  (Celestone Cronodose, Schering-Plough Laboratories). (I give 10 mg Kenalog )
• Works amazingly well for side locked frontal headaches where tenderness is in trochlear area.

Occipital nerve blocks have had beneficial effectws oon migraine headaches, especially if there is tenderness there (there always is)

The greater occipital nerve is very close to midline – though literature says classically 2.5 cm = 1 inch from midline. You can actually feel a thread and  If you are lucky, you can feel a pulse, though the patient will point out the most tender area. For years, I would inject directly but now it is obvious then nerve is close to the dermis so using a bent needle  keeps you in the superficial tissues where the nerve runs – you can fan needle back and forth over various angles until catch a shotting pain catching nerve – and inject near  shotting site. Now I just inject superficial to the thread.

Lesser occipital nerve is some behind mastoid and needs doing as well. I use  6% liodocaine up to 2 mls in younger and 1-1.5 mls in older patients – and repeat up to 3 times.

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Corrigator botox- For some, the headache is coming more from the frown muscles anteriorly – sometimes you can see hypertrophy of the corrigator muscles as well. Injection there with botox is beneficial:

Headache. 2003 Nov-Dec;43(10):1085-9.
Single-site botulinum toxin type a injection for elimination of migraine trigger points.
Behmand RA, Tucker T, Guyuron B.
http://www.migrainesurgery.co.uk/uk/assets/downloads/international_publications/ip3_behamed.pdf

• study injected 25 units into each corrigator –  I have gotten results from using “leftovers” from other peoples botox – ie – 5-10 units each

Technique:

Results:

• At 2 months, 24 (83%) of 29 patients reported a positive response to the injection of botulinum toxin type A (P <.001).
• Sixteen patients (55%) reported complete elimination of headache (P <.001), 8 (28%) experienced significant improvement (at least 50% reduction in frequency or intensity) (P <.04), and 5 (17%) did not notice a change in headache.
• The duration of efficacy of the botulinum toxin type A injections ranged from 6 to 12 weeks, with an average of 8 weeks.
• In patients who had improvement in migraine but not complete elimination, the headache frequency decreased from 6.4 to 2.1 per month on average (P <.04), and the intensity decreased from 8.6 to 6.1 (P <.04).
• Their botox was dissolved in saline – perhaps if lidocaine was used, the nerve block resultant could have helped, as local does not seem to effect its potency.

Comment – I do these nerve blocks on resistent headaches – they come back when shots have worn off – it is funny how some will point to exact spot wishes done.

For the ultimate bad chronic headaches
I give both ketamine and semi-neurolytic lidocaine injections. The ketamine is based on a poster study of 15 min sapced ketamine doses for headaches and neuropathic pains.

INTRAMUSCULAR (IM) KETAMINE FOR TREATING MIGRAINE AND NEUROPATHIC PAIN IN THE CLINIC
John Claude Krusz, PhD, MD, Stephanie Hall, BS, MPH, Jane Cagle, LVN
Anodyne Headache and PainCare, Dallas    free poster here

• 10 chronic headache and 7 chronic radiculopathy cases
• Pulse oximetry (I only use if drowsy and haven’t needed it at dose I use))
• 0.3-0.4 mg per kilogram of ketamine was used. The average dose of ketamine was 68.3 mg. – I have concerns about patient getting Bladder frequency complications from ketamine but has never been a problems at low dose
• “The dose was injected in three to four portions intramuscularly, with 10 to 15 minutes between injections”. Injections are nearly painless as drug causes no irritation. I use a 30 gauge needle.
• Shots repeated in 24 hours if return symptoms;  One patient received 11 sets of injections for frequent refractory migraines.
• Neuropathic pain relief was good

I give ketamine 10 mg x2 IM deltoid each dose 15 min apart twice a week and semineurolytic lidocaine shots to various head triggers – subject will often pick spots for you. Doing that, you may get subject off painkillers (except tramadol) which will be the problem 1/2 the time anyway. Have one lady who was unemployed, and at one point bedridden;  now working over 1/2 time.

No one has mentioned the auriculotemporal nerve in temple – I wonder if some TMJ aggravated headaches need shots there if tender… The lesser occipital nerve has been cited for causing headaches and might need injecting if tender.

Addendum –

Dealing with resistant chronic headaches can unmask multiple issues:

gentleman late 20’s – constant headaches since car accident 3 years prior. In chronic pain -on opioids

am trying low dose topiramate (15 mg) – poor med tolerance

c4-6 right facets, unilateral interscapular pains with the bent  T2 dorsal nerve root – dextrose 5% – glycerin 3% desensitization. Obviously very tender at c 4-6 -activator mobilized suspect facet syndrome feeds headaches some. needs injection ? botox

severe pain right trochlear area – injected with kenalog 20 mg.

Right shoulder tip pains – first rib, levator scap and trapezius tip – Mobs to rib, injected with local and brutal transverse massages. Suspect holds considerable stress there.

severe tender occipital  nerves – began every 3rd day blocks – turns out his greater occipital nerve bifurcates into 2 so 4 injections there, lesser occipital nerves, and 3rd occipital nerves all tender –  injected  5% lidocaine with 3% glycerin – then bilateral supraorbial blocks in front

Not sleeping well and amitriptyline issues prior so settled on zanaflex 2-4 mg hs (got 5 hours on 2 mg – just starting 4 mg).

daily migraine like headaches severe – daily ketamine injections  – after day 3 migraines began to fade but right temple – orbital area.  Turns out lost tooth on left side so only chews on right – will need soft diet and orthodontics that cannot afford… will be next challenge.

Headaches not just right sided – considering trail of indomethacin (but has bad stomach and already on nexium)

I s having major problems with “Ex” and don’t expect remission until he sees a lawyer… Ketamine has been controlling mood…but probably needs to stop opioids

Just dealing with one issue would have not helped – has:
excessive stress
insomnia
opioid induced headaches
post traumatic headaches
migraines
right trochleitis
c4/5/6 facet-interscap referred pains and other neck pains
Right shoulder tip/1st rib area pains
occipital neuralgia and suboccipital level pains
TMJ and myofascial related pains
suspect will have a few more issues  by time I am finished