Greater Occipital Nerve Blocks Help Triptan Overuse Headaches

Triptan overuse can exacerbate and well as signify uncontrolled headaches. Use of Occipital nerve blocks can make transition of limiting triptans easier.

Acta Neurol Scand. 2017 Apr;135(4):426-433. doi: 10.1111/ane.12692.
Greater occipital nerve block in the treatment of triptan-overuse headache: A
randomized comparative study.
Karadaş Ö et al.
https://www.ncbi.nlm.nih.gov/pubmed/27666722

  • GON site- 2 cm lateral and 2 cm inferior of the external occipital protuberance. Patients  face down on the examination couch.
  • Reach periostiun with 26- G 0.45 × 13- mm needle, and then pulled the needle
    1 mm back
  • Injected lidocaine  bilateral 2.5 mL injection
  • local pressure was applied  one minute.
  • 3 stage was once every 3 weeks
  • results were at 2 and 4 months

Results: – frequency less and severity was similarly less.Triptam Withdraw Headaches- GON Blocks Help Comment – not sure needed bilateral shots if only one Occipital nerve tender. More commonly sore is the 3rd occipital nerve which in within 4 mm of spinous process c2  and often in the c2-occiput interspace. Better results could be gotten with 5% licocaine (2 ml max – 1.5 ml elderly):
J Headache Pain. 2010 Dec;11(6):519-23. doi: 10.1007/s10194-010-0244-x.
Adverse effect profile of lidocaine injections for occipital nerve block in occipital neuralgia.
Sahai-Srivastava S et al
https://www.ncbi.nlm.nih.gov/pubmed/20665065

and if dose under 1 ml (0.75 ml elderly) then 10% lidocaine:
J Pain Res. 2016 Sep 29;9:721-725. eCollection 2016.
Prolongation of greater occipital neural blockade with 10% lidocaine neurolysis:
a case series of a new technique.
Kim DD et al
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5047742/pdf/jpr-9-721.pdf

Tinting lidocaine with little methylene blue, makes it last much longer…

It is not hard to feel a tract of tissue where the nerve runs. If you bend the needle 30 degrees and inject in along tract, you can get a paresthesia and then inject. The 3rd occipital nerve is within 5-10 mm  spinous process – I just inject lateral to it and use the bent needle routine to find it.

My plan is to beat down the occipital nerves until they are not tender -which usually takes 3 consequentive  week injections – waiting 3 weeks it comes back – mind you, with 3 consequentive weekly injection, tenderness could be back in 3 weeks…

Comment – I would usually give triamcinolone 60 IM to help stop the status migraine and use Ketamine daily as well during transition:
Simulating Ketamine Infusions with Repeated Detoid Muscle Injections
http://painmuse.org/?p=4993

Suboccipital and if frontal headaches Supraorbital injection (the latter with 5% lidocaine is rather painful even with ice cooling pre-treatment – so might want to use buffered 1% lidocaine in front)

Topirimate is my preferred migraine preventative agent- though with a history of kidney stones will need something else. NSAID’s may be of help early one.

Basically 3 shots cut headache pains in about 1/2 in 4 months which is similar to a recent other article:
Chronic Migraines – Repeated Occipital Nerve Blocks Cut pain in 1/2 in 3 Months
http://painmuse.org/?p=5300

 

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