What is an occipital nerve block?

From the Guidelines

We suggest greater occipital nerve block for the short-term treatment of migraine. The procedure typically uses a mixture of a local anesthetic (like lidocaine 1-2% or bupivacaine 0.25-0.5%) and a corticosteroid (such as methylprednisolone 40-80mg or triamcinolone 40mg) 1. For the greater occipital nerve block, the injection site is approximately one-third of the distance from the occipital protuberance to the mastoid process, about 2-3cm lateral to the midline. After cleaning the area with antiseptic solution, a 25-27 gauge needle is inserted perpendicular to the skin until bone is contacted, then withdrawn slightly before injecting 2-3ml of the medication mixture. Patients may experience immediate relief from the anesthetic, with the steroid providing longer-lasting anti-inflammatory effects over days to weeks. Potential side effects include temporary numbness, dizziness, injection site pain, and rarely, infection or nerve damage. The procedure works by reducing inflammation and interrupting pain signals from the occipital nerves to the brain, making it effective for conditions like occipital neuralgia, cervicogenic headaches, and some types of migraines.

Some key points to consider:

• The evidence for greater occipital nerve block is based on a single RCT that showed improvement (reduced pain) versus placebo 2.
• The overall quality of the evidence was deemed low, but the benefits of greater occipital nerve blockade were found to outweigh the risks, with no serious adverse events reported 1.
• The procedure can be easily learned and performed by primary care physicians and other clinicians, and it is less resource-intensive than intravenous treatment 1.
• Greater occipital nerve block may be offered to patients with postdural puncture headache (PDPH) after spinal anesthesia with a narrower-gauge (22 G) needle, although headache may recur in a substantial proportion of patients 3.

However, it is essential to note that:

• There is insufficient evidence to recommend for or against greater occipital nerve block for the prevention of chronic migraine 2.
• The use of greater occipital nerve block for PDPH after dural puncture with wider-gauge needles is unclear, with low certainty of evidence 3.

In summary, greater occipital nerve block is a suggested treatment for short-term migraine relief, but its effectiveness for other conditions, such as chronic migraine or PDPH, is less clear and requires further research.

From the Research

Occipital Nerve Block

• The occipital nerve block (ONB) is a treatment option for occipital neuralgia, a condition characterized by sharp, stabbing pain in the upper neck, back of the head, and behind the ears 4.
• ONB involves the injection of a local anesthetic, such as lidocaine or bupivacaine, and corticosteroids into the greater or lesser occipital nerve to relieve pain 5.
• Studies have shown that ONB is an effective treatment for occipital neuralgia, with significant reductions in pain intensity and improvements in patient satisfaction 5, 6.

Indications and Selection Criteria

• ONB is indicated for the treatment of occipital neuralgia, cervicogenic headache, cluster headache, and migraine 7.
• Selection criteria for ONB include tenderness to palpation of the occipital nerve and reproduction of headache pain with nerve pressure, although these criteria are not necessary for all types of headaches 7.

Techniques and Outcomes

• The technique of ONB involves the injection of a local anesthetic and corticosteroids into the affected nerve, with or without the use of ultrasound guidance 5, 6.
• Studies have reported significant reductions in pain intensity and improvements in patient satisfaction after ONB, with some patients experiencing long-term relief 5, 8.
• The duration of relief after ONB can vary, with some patients experiencing short-term relief and others experiencing longer-term benefits 8.

Comparison with Other Treatments

• ONB has been compared to other treatments for occipital neuralgia, including botulinum toxin injections, radiofrequency ablation, and surgical decompression 6, 8.
• While ONB is considered a first-line treatment for occipital neuralgia, other treatments may be necessary for patients who do not respond to ONB or who experience recurrent pain 8.