What are the preventatives for occipital headaches?

Preventative Treatments for Occipital Headaches

Greater occipital nerve block is the most effective preventative treatment for occipital headaches, with evidence supporting its use for short-term treatment of migraine and occipital neuralgia. 1, 2

Pharmacological Preventatives

First-line Medications

• Amitriptyline is recommended for prevention of chronic tension-type headache and occipital neuralgia, with dosages ranging from 30 to 150 mg/day 1, 3
• Antiepileptic medications (such as gabapentin, pregabalin) are effective preventive treatments for occipital neuralgia 3
• For patients with occipital headaches related to migraine, beta-blockers (propranolol 80-240 mg/day, timolol 20-30 mg/day) have strong evidence for efficacy 1

Second-line Medications

• Calcium channel blockers have limited evidence for efficacy in occipital headaches, with flunarizine (10 mg/day) showing better results than verapamil, which has poor quality evidence 1
• Serotonergic agents like methysergide can be effective but require drug holidays (3-4 weeks after each 6-month course) due to risk of fibrosis 1
• NSAIDs may be used for prevention in some cases, though evidence is stronger for their use in acute treatment 1

Procedural Interventions

Nerve Blocks

• Greater occipital nerve block with local anesthetics and/or corticosteroids is both diagnostic and therapeutic, providing relief lasting weeks to months 1, 2
• The procedure involves injection near the occipital nerves at the base of the skull, temporarily numbing or reducing inflammation 2
• Side effects are generally minimal and include numbness, tingling, and local discomfort at the injection site 2

Neurostimulation

• Occipital nerve stimulation (ONS) should be considered for drug-resistant chronic occipital headaches, particularly those related to cluster headache 4, 5
• Long-term studies show 52.9% response rate (defined as at least 50% improvement in attack frequency) with ONS 5
• ONS involves implanting a subcutaneous electrode connected to a generator that delivers electrical stimulation to the occipital nerves 6
• Potential adverse events include battery depletion (70% of patients) and electrode migration (20% of patients) 4
• Pulsed radiofrequency of upper cervical nerves may be considered for refractory cases, though evidence is insufficient to make a strong recommendation 1, 3

Non-pharmacological Approaches

• Physical therapy is recommended for management of tension-type, migraine, or cervicogenic headache 1
• Aerobic exercise or progressive strength training is suggested for prevention of tension-type and migraine headache 1
• Behavioral interventions (biofeedback, cognitive behavioral therapy, mindfulness, progressive muscle relaxation) have insufficient evidence but may be considered 1

Treatment Algorithm

1. Start with physical therapy and lifestyle modifications (aerobic exercise, progressive strength training) 1
2. Add first-line preventative medication (amitriptyline for tension-type headache; antiepileptics for occipital neuralgia; beta-blockers for migraine-related occipital pain) 1, 3
3. If inadequate response after 2-3 months, consider greater occipital nerve blocks 1, 2
4. For refractory cases, consider occipital nerve stimulation, particularly for those with chronic cluster headache component 4, 5

Important Considerations

• Medication overuse can worsen headaches; limit use of acute medications to avoid this complication 1
• Preventive treatments may take 2-3 months to show full benefit; adequate trial periods are necessary 1
• After a period of stability, consider tapering or discontinuing preventive treatment 1
• For patients with multiple headache types, a combination approach targeting each specific headache mechanism may be necessary 5