“In lieu of the efficacy of peripheral nerve blocks and given the relatively high side effect profiles of many headache prophylactic medications, I hope that clinicians think twice before treating older adults and geriatric patients with oral pharmacotherapy for headache prophylaxis,” noted one of the study authors, Jacob R. Hascalovici, MD, PhD, from Montefiore Medical Center at Albert Einstein College of Medicine in the Bronx, New York. “Specifically, the medications that are considered contraindicated in the older adult and geriatric population according to the Beers Criteria medication list.”4
Decompression may be key to pain relief
In patients with unremitting head and neck pain, occipital nerve decompression surgery may provide lasting relief by freeing the lesser and greater occipital nerves at the level at which they innervate the posterior cervical muscles. Pain in these patients may present like a chronic migraine, for which the centrally acting membrane-stabilizing agents are not effective.5
“It is helpful to think of occipital nerve compression in the same way that we would think of other nerve compression syndromes, perhaps carpal tunnel syndrome,” said neurologist Pamela Blake, MD, from the University of Texas Health Science Center in Houston. “We would likely start with interventions directed at reducing the nerve compression, such as immobilizing with wrist splints at night, and counseling the patient to avoid activities that provoke nerve irritation. I would encourage a somewhat similar approach to a patient with occipital nerve compression, with treatments directed at the nerves — perhaps occipital steroid injections and counseling the patient to avoid the neck positions that may aggravate pain — and perhaps try 2 or 3 oral preventives.”
Repetitive pericranial nerve blocks for paroxysmal hemicrania
For the rare cases of paroxysmal hemicrania that are refractory to treatment with indomethacin, interventions such as repetitive pericranial nerve blocks may provide relief.6 Because the incidence of paroxysmal hemicrania is so rare — as are patients who are resistant to indomethacin — the evidence base is too small to recommend one modality over another.
“Interventional headache management therapies using local anesthetics with or without corticosteroids are inexpensive and affordable treatment options,” explained neurologist Devrimsel Harika Ertem, MD, from the Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences in Istanbul, Turkey.
“However, the effects of cranial nerve blocks in patients with chronic paroxysmal hemicrania still remain unclear,” noted Dr Ertem. “Neuromodulation procedures, such as occipital nerve stimulation, vagus nerve stimulation and deep brain stimulation in the posterior hypothalamus are promising treatment options for patients with headache who are unable to tolerate indomethacin. Unexpected bleeding, pain at injection sites, local anesthetics toxicity, iatrogenic pneumothorax, and nerve injury are rare but side effects of interventional therapies that should not be ignored.”
Summary & Clinical Applicability
Interventional pain modalities provide alternative analgesia for patients who are intolerant of pharmacologic agents, have comorbidities that require multiple medications, or have pain refractory to oral medications. Large randomized prospective trials are needed to test the efficacy of these modalities.
1. Gupta R, Fisher K, Pyati S. Chronic headache: a review of interventional treatment strategies in headache management. Curr Pain Headache Rep. 2019;23(9):68. doi:10.1007/s11916-019-0806-9
2. Binfalah M, Alghawi E, Shosha E, Alhilly A, Bakhiet M. Sphenopalatine ganglion block for the treatment of acute migraine headache. Pain Res Treat. 2018;2018:2516953. doi:10.1155/2018/2516953
3. Hascalovici JR, Robbins MS. Peripheral nerve blocks for the treatment of headache in older adults: a retrospective study. Headache. 2017;57(1):80-86. doi:10.1111/head.12992
4. 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019;67(4):674-694. doi:10.1111/jgs.15767
5. Blake P, Burstein R. Emerging evidence of occipital nerve compression in unremitting head and neck pain. J Headache Pain. 2019;20(1):76. doi:10.1186/s10194-019-1023-y
6. Ertem DH. Are repetitive pericranial nerve blocks effective in the management of chronic paroxysmal hemicrania?: a case report. Medicine (Baltimore). 2019;98(31):e16484. doi:10.1097/MD.0000000000016484