Steroid Dosing in Supratrochlear Supraorbital Nerve Block
For supratrochlear supraorbital nerve blocks, the typical steroid dose is 20-40 mg of methylprednisolone or 4-10 mg of dexamethasone, with higher concentrations (dexamethasone 10-24 mg/mL or methylprednisolone 30-40 mg/mL) showing better outcomes.
Steroid Options and Dosing
- Dexamethasone is commonly used at concentrations of 4-24 mg/mL, with higher concentrations (24 mg/mL compounded or 10 mg/mL stock) showing better clinical outcomes 1
- Methylprednisolone is typically used at concentrations of 30-40 mg/mL 1
- A typical injection volume is 0.4-0.8 mL per site, resulting in a total dose of approximately:
- Dexamethasone: 4-10 mg per injection
- Methylprednisolone: 20-40 mg per injection 1
Administration Technique
- For nerve blocks, the steroid is typically mixed with local anesthetic 2, 3
- Common local anesthetics used include:
- Lidocaine 1-2%
- Bupivacaine 0.5% 2
- The injection is performed at the site where the supratrochlear and supraorbital nerves exit their respective foramina 4
- Patients should be monitored for 15-30 minutes after injection to ensure proper distribution of the medication 1
Evidence on Efficacy
- Studies examining nerve blocks for headache conditions have shown mixed results regarding the added benefit of steroids 2, 3
- One study found that adding 40 mg of triamcinolone to local anesthetic for occipital nerve blocks did not provide additional benefit compared to local anesthetic alone 2
- Another randomized controlled trial using 20 mg of methylprednisolone with bupivacaine for occipital nerve blocks also showed no significant advantage over placebo 3
Comparative Steroid Potency
- When selecting a steroid, it's important to understand relative potencies:
- Dexamethasone is 25 times more potent than hydrocortisone
- Methylprednisolone is 5 times more potent than hydrocortisone
- Prednisone is 4 times more potent than hydrocortisone 1
- The equivalent dose of prednisone 60 mg is approximately 48 mg for methylprednisolone and 10 mg for dexamethasone 1
Potential Side Effects
- Local side effects may include:
- Pain at injection site
- Transient dizziness
- Infection
- Vasovagal episodes during injection 1
- Systemic side effects are less common with local injections but may include:
- Elevated blood sugar
- Elevated blood pressure in susceptible patients 1
Clinical Pearls
- Higher concentrations of steroids appear to provide better outcomes, though evidence is limited 1
- A small retrospective study showed that dexamethasone 24 mg/mL resulted in better outcomes than 10 mg/mL concentration 1
- For nerve blocks used in headache treatment, multiple injections (typically 2-4) over a 2-week period may be required for optimal effect 1
- When performing nerve blocks for orofacial conditions, volumes of 3-10 mL of triamcinolone (10 mg/mL) have been used successfully 5
Pitfalls to Avoid
- Underdosing steroids is a common pitfall; ensure adequate concentration and volume are used 1
- Avoid using steroid preparations with preservatives when possible, as they may cause additional irritation 6
- Be cautious in patients with diabetes, as even local steroid injections can affect blood glucose levels 1
- Consider the duration of action when selecting a steroid - dexamethasone typically has a longer duration of effect than methylprednisolone 6