1.Headache - 2022 - Stern - Narrative review of peripheral nerve blocks for the management of headache (1).pdf

Narrative review of peripheral nerve blocks for the management of headache

Jennifer I. Stern MD1 | Chia- Chun Chiang MD1 | Narayan R. Kissoon MD1,2 | Carrie E. Robertson MD

1Headache Division, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA 2Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA

Headache. 2022;62:1077–1092.

Summary

• Peripheral nerve blocks have been used for decades in the treatment of cranial neuralgias and multiple headache disorders, including
  • migraine
  • cluster headache
  • and cervicogenic headache.
• the greater occipital nerve (GON) is the most common target.
• Some centers will block the lesser occipital nerve (LON) together with the GON
• The supraorbital (SON), supratrochlear (STN), and auriculotemporal (ATN) nerves are also common nerve targets.
• The precise mechanism underlying prolonged headache relief following nerve blocks is unknown, but may involve central pain modulation
• The upper cervical nerve roots are anatomically and functionally connected to trigeminal pathways
• Interestingly, anesthetic blockade of the GON, from the posterior division of C2, has been demonstrated by electrophysiology and functional imaging to reduce activation of trigeminal nociceptors
• The most common local anesthetics used in RCTs include short- acting lidocaine (1%, 2%, occasionally 5%) and long- acting bupivacaine (0.25% or 0.5%)
• lidocaine and bupivacaine dosing in a given session should be limited to a maximum of 300 and 175 mg, respectively.

Greater Occipital Nerve Block

• GON arises from the posterior division of C2 and gives sensation to the medial portion of the posterior scalp
• To find the location of the GON,
  • The method most used in RCTs involves palpating the occipital protuberance and mastoid process.
  • The target area for the GON block is approximately one third of the distance between these two points, starting from the occipital protuberance
  • Another method uses distance from the occipital protuberance, typically 1.5– 2 cm lateral and 2– 3 cm inferior
  • The occipital nerve is often, but not always, just medial to the artery
  • palpate for an area of maximal tenderness, as this may increase the accuracy of the block
• use a 25- , 27- , or 30- gauge needle and a 3 or 5 ml syringe