Occipital Nerve Block, an Effective Option for Pediatric Headache

A high prevalence of headache has been noted in children and adolescents. In a 2013 review of 64 cross-sectional studies from 32 countries that included a total of 227,249 participants, the estimated overall mean prevalence of headache and migraine in this population were 54.4% (95% CI, 43.1%-65.8%) and 9.1% (95% CI, 7.1%-11.1%), respectively.¹

The management of pediatric headache often includes lifestyle modification counseling, pain relief with over-the-counter medications or triptans, and measures to avoid medication overuse. However, the available therapies have proven ineffective for some patients who may have chronic, treatment-refractory headache.

“Seeing children and adolescents [who have] hard to treat acute and chronic headaches is difficult,” said Alexander Sasha Dubrovsky, MDCM, MSc, FRCPC, a pediatric emergency medicine physician at the Montreal Children’s Hospital in Quebec. “Peripheral nerve blocks of the scalp — especially greater occipital nerve blocks — offer physicians one additional tool in their armamentarium to help provide relief,” he told Clinical Pain Advisor.

The use of peripheral nerve blocks is well established in the treatment of headache disorders in adults, with demonstrated effectiveness for migraines, cluster headaches, primary cervicogenic headaches, and occipital neuralgias. Findings regarding the use of peripheral nerve blocks in children, however, have begun to emerge only recently. Dr Dubrovsky conducted a narrative review of studies investigating the utility of the technique in pediatric patients with headache disorders. His findings were recently published in Current Pain and Headache Reports.²

Results of studies that met inclusion criteria (ie, studies that included original data, focused on a pediatric population, and involved the use of nerve blocks for headache treatment in human subjects) are summarized below.

A retrospective chart review (n=40) published in 2014 reported outcomes of 40 patients with daily persistent headaches or chronic migraine who received unilateral occipital nerve block using 2% lidocaine and methylprednisolone.³ More than half of patients benefited from the treatment, and 28% showed significant benefit (improvement lasting >1 month, with reduction in headache frequency, duration, and intensity by at least one-third). Treatment effects lasted up to 16 weeks (mean, 5.4 weeks).

A conference abstract reported on the use of bilateral occipital nerve blocks using bupivacaine and methylprednisolone in 38 teen girls with chronic daily headaches and fibromyalgia.⁴ In this study, improvement in pain and function was observed in 61% and 76% of patients at 2 weeks and 2 months posttreatment, respectively.  

In another conference abstract, 70% of teens (n=17) with chronic migraine reported complete resolution at 2 weeks following unilateral occipital nerve block with lidocaine and methylprednisolone.⁵

In a retrospective cohort study conducted by Dr Dubrovsky and colleagues, occipital nerve block with 2% lidocaine was performed in 28 children with posttraumatic headaches.⁶ The researchers found that 93% of patients demonstrated “good” therapeutic effect (ie, lasting >24 hours), and 71% reported complete resolution of headaches. In comparison, in a group of patients who received intravenous metoclopramide prior to receiving the nerve block, complete resolution was reported by only 32% of patients.

Findings from a 2014 study indicate that 64% of teenage patients (n=14) with postconcussion syndrome and chronic headaches experienced a reduction in headache frequency of at least 50% following greater occipital nerve block with lidocaine and triamcinolone.⁷ In addition, the mean headache frequency decreased from 26 days to 17 days per month.

In a small case report (n=3) of patients with sports-related concussions and headache, unilateral greater occipital nerve block administered 6 weeks postinjury led to immediate pain relief that persisted for several weeks.⁸

According to Dr Dubrovksy and colleagues, greater occipital nerve block may be effective in relieving headache, as the injection of a local anesthetic “into the area just beside where the nerve emerges in the trapezius aponeurosis and in close proximity to where it surfaces from the semispinalis capitis muscle, an interruption of the nerve signal occurs along with some degree of hydrostatic dissection along its course.² By anesthetizing the foci of nociceptive discharges, the normal neuron sensitivity may be re-established, and at the same time, the hydrostatic dissection may decrease tension formed at potential sites of nerve entrapment, thereby eliminating the source of this contributing headache generator.”

Dr Dubrovsky assesses for greater occipital neuralgia during the physical examination portion of a comprehensive patient assessment, and he offers nerve block as a pain relief option for any patient with occipital neuralgia and moderate to severe pain (with an intensity >3 on a 0 to 10 scale). He also discusses the potential benefits of the technique, as well as the risks, which are extremely low. “It is a relatively easy procedure with nearly no risk, and it will offer significant relief to many of these children,” he said. “This is a must-learn for all clinicians caring for children with headaches.”

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References

1. Wöber-Bingöl C. Epidemiology of migraine and headache in children and adolescents. Curr Pain Headache Rep. 2013; 17(6):341.
2. Dubrovsky AS. Nerve blocks in pediatric and adolescent headache disorders. Curr Pain Headache Rep. 2017; 21(12):50.
3. Gelfand AA, Reider AC, Goadsby PJ. Outcomes of greater occipital nerve injections in pediatric patients with chronic primary headache disorders. Pediatr Neurol. 2014;50(2):135-139.
4. Lacey DJ. Efficacy of greater occipital nerve blocks (ONBs) in the treatment of chronic daily headaches (CDH) in adolescent females with fibromyalgia. Presented at: American Headache Society 56th Annual Scientific Meeting; June 26-29, 2014; Los Angeles, CA. Abstract P30.
5. Renaudon-Smith ETC, Toolis C, Goadsby PJ, Prabhakar P. Greater occipital nerve injection (GONI) for chronic headache in children. Presented at: 2nd European Headache and Migraine Trust International Congress; October 28-31, 2010; Nice, France. Abstract 317..
6. Dubrovsky AS, Friedman D, Kocilowicz H. Pediatric post-traumatic headaches and peripheral nerve blocks of the scalp: a case series and patient satisfaction survey. Headache. 2014; 54(5):878-887.
7. Seeger TA, Orr S, Bodell L, Lockyer L, Rajapakse T, Barlow KM. Occipital nerve blocks for pediatric posttraumatic headache: a case series. J Child Neurol. 2015; 30(9):1142-1146.
8. Zaremski JL, Hurley RW, Herman D, Bauer RM, Ahn AH. Occipital neuralgia blockade as a treatment after concussions. A case series. Presented at: American Academy of Physical Medicine and Rehabilitation 2014 Annual Assembly; November 13-16, 2014; San Diego, CA. Poster 182.