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.
- 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
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
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
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