CASE SERIES – Interventional pain management techniques can be helpful in headache management
* University of Cambridge, Cambridge (UK),
**Pain Management Centre, Omer Medical Complex, Raiwind City (Pakistan).
In this case series we present three different interventional procedures used to treat headache. The procedures, e.g. occipital nerve block, cervical injection and trigger point injection, are described and the supporting literature is reviewed.
Key Words: Emergency department (ED); migraine; cervical injections; trigeminovascular system; cephalgia; occipital nerve block; trigger point injection
Citation: Bano I, Chaudhary WA, Ashfaq M. Interventional pain management techniques can be helpful in headache management. Anaesth Pain & Intensive Care 2011;15(1):60-64.
The lifetime prevalence of headache is over 90%. The reported prevalence of migraine headaches is 18.2% among females and 6.5% among males. Headache is a common complaint for which patients seek relief in the emergency department (ED). The management of headache in UK EDs includes an armamentarium of medications delivered by the oral, subcutaneous, intramuscular, or intravenous routes. It has been characterized as a “broad pharmacopeia of medications” with opioids commonly administered, especially meperidine. While the most effective treatment for primary headaches is intravenous prochlorperazine (typically administered with diphenhydramine to counteract the common side effect of akathisia)1-4, there are other therapeutic techniques that involve intramuscular injections of local anesthetics. This technically simple procedure is rapidly accomplished, and results are gratifying in that the relief occurs in five to 10 minutes. The technique is becoming increasingly accepted as a therapeutic modality for treating headache. In this case series, we used three different procedures to treat headache including occipital nerve blocks, cervical injections and trigger point injections.
Patients’ length of stay in the ED appears to be shortened. Based on the rapid resolution of headache and other trigeminovascular system-related signs and symptoms following these injections, connections to the trigeminal system appear to be involved. Three patients illustrative of the therapeutic response to the lower cervical injection with inj. bupivacaine are presented.
(Migraine without Aura: Cervical Injection)
A 31 year old female presented to the ED for pain relief from migraine headache, that started three days earlier. She complained of light sensitivity, nausea and vomiting. Routine abortive medications were attempted but without relief. The headache began on the left hemicranium, but became bilateral and was 10/10 in severity on VAS. The patient denied having any other medical problem. She was treated with 1.5ml of inj. bupivacaine 0.5% at either side of the spinous process of the C-7 vertebra. In less than five minutes she experienced relief of her headache to 1/10. She also described complete relief of her photophobia and nausea. Subsequently, the patient reported that she did not have her usual postdromal headache that typically affected her during the following 24 hours. Nine days later she returned to the ED with a migraine headache initiated by the ‘smell of a strong cologne’. Again, photophobia and nausea accompanied the headache. The patient again received bilateral intramuscular injections of 1.5ml of 0.5% bupivacaine at the level of C-7 spinous process. The time from the local anesthetic injections to complete headache relief was exactly seven minutes. The patient had two subsequent visits to the ED for similar migraine headaches over several months and responded consistently to the cervical injection therapy.
(Episodic Tension Headache: Cervical Injection)
A 47-year-old female complained of a constant frontal, unilateral headache for three days prior to arrival in the ED. Similar headaches would occur ‘every now and then’. The patient described the headache as a tight band about her head. She denied an aura, numbness, phonophobia, photophobia, nausea, or vomiting. Even though she reported feeling ‘congested’, there was no clinical evidence of sinusitis. The headache was 6/10 in severity. Bilateral lower cervical injection with 1.5ml of 0.5% bupivacaine resulted in complete resolution (0/10) of the headache in approximately six minutes. During follow-up, the patient confirmed that she remained headache-free after leaving the ED, and that she was able to return immediately to her daily activities.
(Acute Post-traumatic Headache: Cervical Injection)
A 25 year old male sustained a head injury and orofacial trauma after collision with a car while driving a motorbike. A brief loss of consciousness occurred. Additionally, there was avulsion and subsequent reimplantation of the right maxillary central incisor as well as extrusive subluxation of the mandibular central incisors. Since the accident the patient had experienced continuous, severe right maxillary dental pain with hypersensitivity to cold water and light touch. He also experienced significant dental and gingival pain in the subluxated but stabilized teeth. His pain was unresponsive to hydrocodone with acetaminophen or oxycodone with acetaminophen. In addition, the patient reported a constant, throbbing, posterior headache rated at 7–10/10 in severity. A C-7 paraspinous intramuscular bupivacaine injection was performed bilaterally. Not only was the patient’s headache relieved, his dental pain was reduced to 1/10 in severity. After the injection, the patient was able to bite down, drink water, and run cold water over his previously painful teeth. During the follow-up, the patient reported that his dental pain remained diminished and that the headache did not return.
(Occipital Neuralgia: Occipital Nerve Blocks)
A 41 year old male presented to the ED for evaluation and management of his headache of recent onset. The patient described intermittent shooting pains that seemed to originate from the right occipital area. The clinical presentation was consistent with the diagnosis of occipital neuralgia. The headache had been present for over a week and had not responded to over-the-counter medications. Palpation over the occipital area easily reproduced the pain. He denied any other associated symptoms and denied any other relevant past medical, social or surgical history. In the ED the injection of bupivacaine 0.5% and methylprednisolone sodium succinate 20 mg with a 25-G needle (1.5 cm) into the muscles of the occipital region along the nuchal line, thus blocking superficial occipital nerves, brought immediate relief to the headache.
(Trigger Point Injections)
A 23 year old female presented for evaluation of headache that had been present for three days. Muscle tenderness was detected by palpation bilaterally over the anterior temporal area and several ml of inj. bupivacaine 0.5% were used to inject these areas. The patient had rapid relief of her headache.
Occipital Nerve Blocks
With this procedure the greater and lesser occipital nerves are anesthetized. These nerves are commonly involved in cervicogenic headaches5 and occipital neuralgia6. However, evidence exists to support the use of occipital nerve blocks for a much larger spectrum of primary headaches7. The greater occipital nerve arises from the C2 nerve root and after traveling deep in the paraspinal musculature becomes superficial just below the superior nuchal line and lateral to the occipital protuberance. The nerve travels just medial to the occipital artery at these locations. The lesser occipital nerve is the terminal branch of the superficial cervical plexus and becomes superficial over the inferior nuchal line. The greater occipital nerve block technique, first involves identifying the nerve at its point of entry to the scalp along the superior nuchal line midway between the mastoid process and occipital protuberance. (Fig. 1) The patient will report pain as the nerve is palpated along this distribution. The point of maximal tenderness should be identified and used as the injection site8,9. The nerve typically exits approximately 3 cm below and 1.5 cm lateral to the inion or bony prominence of the occipital skull. (Fig. 2) The scalp should be cleansed with alcohol or another appropriate antiseptic. Local anesthetic agents commonly used include 2% lignocaine or 0.5% bupivacaine. A corticosteroid is often added to the anesthetic being injected. To reduce patient discomfort, the superficial skin can be anesthetized by creating a small wheal using a 27-gauge needle with 1% or 2% lignocaine. Alternatively, a vapocoolant can also be used to reduce discomfort10,11. A 25-G needle is directed towards the occiput until bony resistance is felt. A small amount of anesthetic is injected at that location. The needle is then pulled back until it is just under the skin then redirected laterally and medially as the anesthetic is injected. As part of the process the paraspinal muscles near the suboccipital region are infiltrated with the anesthetic. Since the smaller third occipital nerve exits medial to and in close proximity to the greater occipital nerve, it too is anesthetized. (Fig. 2) Once the syringe is completely withdrawn, the injected area should be massaged and compressed to allow
Figure1: The injection site for greater occipital nerve block
for better distribution of the anesthetic. An alternative technique consists of anesthetizing the nerve at a more distal site over the occipital ridge. The occipital artery is palpated one-third of the way from the inion to the mastoid process and the injections are made just medial to the occipital artery and then additional injections are made medial and lateral to this point9. Response rates have been reported to be about 85%9. Hypesthesia occurs within 1 to 2 minutes, extending upwards on the scalp to the interaural line. Overall, occipital nerve injections are safe but some adverse side effects such as dizziness, lightheadedness or local tenderness at the site of injection may occur. The use of local steroids has been associated with alopecia and hypopigmentation of the surrounding skin.
Figure2: The injection for greater occipital nerve block
The bilateral lower cervical injections with bupivacaine is a recently reported technique for managing headache pain12,13. Additionally, this procedure also appears to provide some relief to patients with orofacial pain14. The mechanism is currently unknown, but based on the therapeutic response the authors suggest that the sensitized trigeminocervical complex is somehow calmed15-18. Previous work has established that cervical and trigeminal afferents as well as other structures with profound antinociceptive effects converge on the brainstem and are known to synapse with the trigeminocervical complex19,20. Cervical injection is performed at the lower cervical or upper thoracic dorsal spine. The field is cleaned with antiseptic solution such as triclosan 0.25% (Chlorosept), betadine or alcohol swabs. Using a 25-G 1.5-inch needle, 1.5 ml of 0.5% bupivacaine, 1 or 2% lignocaine are the anesthetic options. The needle is inserted 1 to 1.5 inches into the paraspinal muscles, 2-3 cm bilaterally, at C6 or C7 cervical vertebrae12,21. The entire amount of anesthetic solution selected (1.5 ml) is deposited in each injection site. Always withdraw the plunger before injecting to ensure that needle is not in a blood vessel. The injected area can be massaged afterwards to facilitate anesthetic absorption and a band-aid can be placed over the injection sites. While the therapeutic response is typically rapid, it can take up to 20 minutes before the medication effect is noted. If patients do not report any pain relief, other therapeutic techniques should be tried12,21. Patients should be warned about injection site soreness which can last anywhere from 24 to 48 hours. Other potential minor complications of this procedure include, pain and irritation at the site of injection, vasovagal syncope, and hematoma formation. Patients should be informed of these potential risks before the procedure is performed.
Trigger Point Injections
Myofascial trigger points have been postulated as an etiology for headaches23-27 and trigger point injections have been described as successful in the management of these headaches25-27. Brofeldt and Panacek described the relief of headaches following the injection of anesthetic in the suboccipital and anterior temporal areas in their 1998 article27. Their technique is described as a two-step procedure that involves identifying the proper injection site and then administrating the injection. To identify the injection site, various sites on the patients head and neck are palpated with the tips of the index and middle fingers using firm circular pressure while paying close attention to the suboccipital and anterior temporal areas. Anterior pressure is applied to the general area where the greater occipital nerve penetrates the semispinalis capitis muscle located approximately two finger breadths inferior to the superior nuchal line and one to two finger breadths lateral to the occipital protuberance. For the anterior temporal area, pressure is applied to the slight depression just posterior to the lateral orbital rim and superior to the zygomatic arch. According to the authors, the appropriate site for injection is identified when focal pressure reproduces or increases the patient’s headache symptoms. The next step is the intramuscular injection for which a 50/50 mixture of 2% lignocaine and 0.25% bupivacaine buffered with a 1/10 volume of 8% sodium bicarbonate is used. A 27-G needle on a 5 ml syringe is inserted through the area of maximal tenderness until the needle makes contact with the cranium. To make contact with the inferior portion of the occiput bone, the needle is guided in a 45-60 degree angle superiorly. Once the needle is at the periosteum, continuous pressure is applied on the syringe and each focally tender area is ‘fanned’ with 1-5 ml of anesthetic solution by moving the needle in multiple directions, in and out of the tender area. Aspiration to avoid injection into a vessel is generally not recommended if the solution is injected simultaneously during fanning of the needle. Once the syringe is withdrawn, the area of injection is massaged for at least 30 seconds. The injection is considered successful when focal palpation no longer reproduces the headache symptoms27. The authors reported that two-thirds of their patients had a therapeutic response. In the report by Young et al. the combination of 8 ml of 0.05% bupivacaine mixed with 2% lignocaine is preferred for the injections9. Their technique involves identifying the injection sites by palpating for areas of tenderness in the paraspinal, suboccipital and trapezius muscles. A total of 0.5-1 ml are injected per site, with the dose divided between three triangularly oriented sites reached without removing the needle from under the skin9. When the trapezius muscle is injected near the apex of the lung, the authors pinch the muscle to isolate the muscle and decrease the chance of a pneumothorax. Steroids are often added to the anesthetic when trigger point injections are performed9. While the occipital injection location described by these authors is very likely an occipital nerve block and the described paraspinous injections may be similar to the lower cervical injections, the injection of the described trigger points, including temporal, and trapezius muscles, would appear to have some benefit.
In this article we described three different intramuscular anesthetic injections that have reported therapeutic benefit for managing headache pain. While there are multiple therapeutic modalities avai;able to relieve headache, intramuscular anesthetic injections other than greater occipital nerve blocks are currently not widely utilized, recognized or researched. The clinical importance of cervical injections and trigger point injections remains to be further clarified. However, this new injection technique appears to be an effective therapeutic option for the entire spectrum of International Headache Society (IHS) classified headaches, whether it be migraine, tension headache, cluster headache or other trigeminal autonomic cephalalgias.
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