Greater occipital nerve block in chronic migraine

Occipital Nerve Stimulation: An Alternative Treatment of Chronic Migraine

PURPOSE OF REVIEW

This paper will examine the efficacy and safety of occipital nerve stimulation as a non-pharmacological alternative treatment for migraine.

RECENT FINDINGS

Migraine is characterized as a primary headache disorder with possible premonitory and aura phases, both of which vary greatly in symptomatology. The most common treatments for chronic migraine are pharmacological and are aimed at both acute relief (e.g., nonsteroidal anti-inflammatory drugs, triptans, and ergots) and prophylaxis (e.g., propranolol, valproic acid, and topiramate). For patients with medically refractory migraine, acute relief medication overuse can increase the risk of developing more severe and more frequent migraine attacks. Occipital nerve stimulation is a non-pharmacological alternative treatment for chronic migraine, which could eliminate the risk of adverse effects from acute relief medication overuse. Neurostimulation is thought to prevent pain by blocking signal transduction from small nociceptive fibers with non-painful signaling in larger adjacent fibers. Existing data from clinical trials support the overall safety and efficacy of occipital nerve stimulation for the treatment of chronic migraine. However, few large controlled, double-blinded studies have been conducted, due to both practical and ethical concerns. Currently, occipital nerve stimulation is available as an off-label use of neurostimulation for pain prevention but is not approved by the FDA specifically for the treatment of chronic migraine.

The efficacy of greater occipital nerve block for the treatment of migraine: A systematic review and meta-analysis

Greater occipital nerve (GON) block has some potential in treating migraine. We conduct a systematic review and meta-analysis to investigate the impact of GON block on pain management of migraine. We have systematically searched randomized controlled trials (RCTs) assessing the efficacy of GON block versus placebo for migraine in various databases including PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases. The primary outcome is pain intensity. Meta-analysis is performed using the random-effect model. Seven RCTs are included in the meta-analysis. Compared with control intervention in migraine patients, GON block intervention can significantly reduce pain intensity (Mean difference = -1.24; 95% CI = -1.98 to -0.49; P = 0.001) and analgesic medication consumption (Mean difference = -1.10; 95% CI = -2.07 to -0.14; P = 0.02), but has no remarkable impact on head duration (Mean difference = -6.96; 95% CI = -14.09 to 0.18; P = 0.0.06) and adverse events (RR = 0.93; 95% CI = 0.52 to 1.65; P = 0.80). GON block intervention is able to significantly reduce pain intensity and analgesic medication consumption in migraine patients.

The efficacy of greater occipital nerve blockade in chronic migraine: A placebo-controlled study

OBJECTIVE

GON blockade with local anesthetics is an effective treatment for a group of headaches, such as cervicogenic headache, cluster headache, occipital neuralgia, migraine. Our aim was to evaluate the efficacy of greater occipital nerve (GON) blockade in patients with chronic migraine (CM) by using a control group.

MATERIALS AND METHODS

We included 44 CM patients and randomly divide the patients into two groups, as group A (bupivacaine) and group B (placebo) to our study. GON blockade was administered four times (once per week) with bupivacaine or saline. After 4 weeks of treatment, patients were followed up for 3 months, and findings were recorded once every month for comparing each month's values with the pretreatment values. The primary endpoint was the difference in the frequency of headache (headache days/month). VAS pain scores were also recorded.

RESULTS

A total of 44 patients had completed the study; no severe adverse effects had occurred. Group A showed a significant decrease in the frequency of headache and VAS scores at the first, second, and third months of follow-up. Similarly, group B showed a significant decrease in the frequency of headache and VAS scores at the first month of follow-up, but second and third months of follow-up showed no significant difference.

CONCLUSION

Our results suggest that GON blockade with bupivacaine was superior to placebo, has long-lasting effect than placebo, and was found to be effective for the treatment of CM. More studies are needed to better define the safety and cost-effectiveness of GON blockade in CM.

Greater occipital nerve blocks in the treatment of refractory chronic migraine: An observational report of nine cases

AIM

To report the effects of greater occipital nerve (GON) blocks on refractory chronic migraine headache.

METHODS

Nine patients who were receiving the conventionally accepted preventive therapies underwent treatment with repeated GON block to control chronic migraine resistant to other treatments. GON blocking with lidocaine and normal saline mixture was administered by the same physician at hospital once a month (for three times in total). Patients were assessed before the injection and every month thereafter for pain frequency and severity, number of times analgesics were used and any appearant side effects during a 6 mo follow-up.

RESULTS

Eight of nine patients reported a marked decrease in frequency and severity of migraine attacks in comparison to their baseline symptoms; one reported no significant change (not more than 50%) from baseline and did not accept the second injection. GON block resulted in considerable reduction in pain frequency and severity and need to use analgesics up to three months after the injection in the present cases. The patients did not report any adverse effects.

CONCLUSION

Hereby we noticed a remarkable success with refractory chronic migraine patients. We believe that this intervention can result in rapid relief of pain with the effects lasting for perhaps several weeks or even months. Further controlled clinical trials are warranted to evaluate the effect of GON block in the treatment of refractory migraine cases.

Inhibitory effect of high-frequency greater occipital nerve electrical stimulation on trigeminovascular nociceptive processing in rats

Electrical stimulation of the greater occipital nerve (GON) has recently shown promise as an effective non-pharmacological prophylactic therapy for drug-resistant chronic primary headaches, but the neurobiological mechanisms underlying its anticephalgic action are not elucidated. Considering that the spinal trigeminal nucleus (STN) is a key segmental structure playing a prominent role in pathophysiology of headaches, in the present study we evaluated the effects of GON electrical stimulation on ongoing and evoked firing of the dura-sensitive STN neurons. The experiments were carried out on urethane/chloralose-anesthetized, paralyzed and artificially ventilated male Wistar rats. Extracellular recordings were made from 11 neurons within the caudal part of the STN that received convergent input from the ipsilateral facial cutaneous receptive fields, dura mater and GON. In each experiment, five various combinations of the GON stimulation frequency (50, 75, 100 Hz) and intensity (1, 3, 6 V) were tested successively in 10 min interval. At all parameter sets, preconditioning GON stimulation (250 ms train of pulses applied before each recording) produced suppression of both the ongoing activity of the STN neurons and their responses to electrical stimulation of the dura mater. The inhibitory effect depended mostly on the GON stimulation intensity, being maximally pronounced when a stimulus of 6 V was applied. Thus, the GON stimulation-induced inhibition of trigeminovascular nociceptive processing at the level of STN has been demonstrated for the first time. The data obtained can contribute to a deeper understanding of neurophysiological mechanisms underlying the therapeutic efficacy of GON stimulation in primary headaches.

Chronic migraine: risk factors, mechanisms and treatment

Chronic migraine has a great detrimental influence on a patient's life, with a severe impact on socioeconomic functioning and quality of life. Chronic migraine affects 1-2% of the general population, and about 8% of patients with migraine; it usually develops from episodic migraine at an annual conversion rate of about 3%. The chronification is reversible: about 26% of patients with chronic migraine go into remission within 2 years of chronification. The most important modifiable risk factors for chronic migraine include overuse of acute migraine medication, ineffective acute treatment, obesity, depression and stressful life events. Moreover, age, female sex and low educational status increase the risk of chronic migraine. The pathophysiology of migraine chronification can be understood as a threshold problem: certain predisposing factors, combined with frequent headache pain, lower the threshold of migraine attacks, thereby increasing the risk of chronic migraine. Treatment options include oral medications, nerve blockade with local anaesthetics or corticoids, and neuromodulation. Well-defined diagnostic criteria are crucial for the identification of chronic migraine. The International Headache Society classification of chronic migraine was recently updated, and now allows co-diagnosis of chronic migraine and medication overuse headache. This Review provides an up-to-date overview of the classification of chronic migraine, basic mechanisms and risk factors of migraine chronification, and the currently established treatment options.

Short-term effects of greater occipital nerve blocks in chronic migraine: A double-blind, randomised, placebo-controlled clinical trial

Background Greater occipital nerve (GON) blocks are widely used for the treatment of headaches, but quality evidence regarding their efficacy is scarce. Objective The objective of this article is to assess the short-term clinical efficacy of GON anaesthetic blocks in chronic migraine (CM) and to analyse their effect on pressure pain thresholds (PPTs) in different territories. Participants and methods The study was designed as a double-blind, randomised, placebo-controlled clinical trial. Thirty-six women with CM were treated either with bilateral GON block with bupivacaine 0.5% ( n = 18) or a sham procedure with normal saline ( n = 18). Headache frequency was recorded a week after and before the procedure. PPT was measured in cephalic points (supraorbital, infraorbital and mental nerves) and extracephalic points (hand, leg) just before the injection (T0), one hour later (T1) and one week later (T2). Results Anaesthetic block was superior to placebo in reducing the number of days per week with moderate-or-severe headache (MANOVA; p = 0.027), or any headache ( p = 0.04). Overall, PPTs increased after anaesthetic block and decreased after placebo; after the intervention, PPT differences between baseline and T1/T2 among groups were statistically significant for the supraorbital (T0-T1, p = 0.022; T0-T2, p = 0.031) and infraorbital sites (T0-T1, p = 0.013; T0-T2, p = 0.005). Conclusions GON anaesthetic blocks appear to be effective in the short term in CM, as measured by a reduction in the number of days with moderate-to-severe headache or any headache during the week following injection. GON block is followed by an increase in PPTs in the trigeminal area, suggesting an effect on central sensitisation at the trigeminal nucleus caudalis. This trial is registered at ClinicalTrials.gov (NCT02188394).

Greater occipital nerve block for the acute treatment of prolonged or persistent migraine aura

Background

Presently, there is no evidence to guide the acute treatment of migraine aura. We aimed to describe the effect of greater occipital nerve (GON) anaesthetic block as a symptomatic treatment for long-lasting (prolonged or persistent) migraine aura.

Methods

Patients who presented with migraine aura lasting > 2 hours were consecutively recruited during one year at the Headache Unit and the Emergency Department of a tertiary hospital. All patients underwent a bilateral GON block with bupivacaine 0.5%. Patients were followed up for 24 hours.

Results

A total of 22 auras were treated in 18 patients. Auras consisted of visual ( n = 13), visual and sensory ( n = 4) or sensory symptoms alone ( n = 5). Eleven episodes met diagnostic criteria for persistent aura (>1 week) without infarction. The response was complete without early recurrence in 11 cases (50%), complete with recurrence in < 24 hours in two cases (9.1%), and partial with ≥ 50% improvement in six cases (27.3%). Complete responses without recurrence were more common in cases with prolonged auras lasting < 1 week than in those with persistent auras (72.7% vs. 27.3%; p = 0.033).

Conclusions

GON block could be an effective symptomatic treatment for prolonged or persistent migraine aura. Randomised controlled trials are still required to confirm these results.

Effectiveness of Greater Occipital Nerve Blocks in Migraine Prophylaxis

INTRODUCTION

Peripheral nerve blocks have been used in primary headache treatment since a long time. In this study, we aimed to examine the efficiency of greater occipital nerve (GON) block in migraine prophylaxis.

METHODS

Data from migraine without aura patients who had GON block were collected and divided into two groups: Group PGON (n=25), which included patients who were under medical prophylaxis and had GON block, and Group GON (n=53), which included patients who had only GON blocks. Migraine was diagnosed using International Headache Society (IHS) classification. Data of 78 patients were analyzed. Headache attack frequency, headache duration, and severity were compared between and within groups in a 3-month follow-up period.

RESULTS

The decrease in headache parameters after GON block in both groups was significantly similar. Headache attack frequency decreased from 15.73±7.21 (pretreatment) to 4.52±3.61 (3rd month) in Group GON and from 13.76±8.07 to 3.28±2.15 in Group PGON (p<0.05). Headache duration decreased from 18.51±9.43 to 8.02±5.58 at 3rd month in Group GON and from 15.20±9.16 to 7.20±4.16 in Group PGON (p<0.05). Headache severity decreased from 8.26±1.32 to 5.16±2.64 in Group GON and from 8.08±0.90 to 5.96±1.20 in Group PGON (p<0.05). There was no statistically significant difference between the groups in 3rd month after treatment (p>0.05).

CONCLUSION

This study showed significant decreases in headache parameters in both groups. As GON blocks were performed in patients unresponsive to medical prophylaxis, a decrease in the headache parameters in Group PGON similar to that in Group GON can be attributed to GON blocks. Consequently, these results show that repeated GON blocks with local anesthetic can be an effective alternative treatment in migraine patients who are unresponsive to medical prophylaxis or who do not prefer to use medical prophylaxis.

Greater occipital nerve blockade for the treatment of chronic migraine: a randomized, multicenter, double-blind, and placebo-controlled study

OBJECTIVES

We aimed to assess the efficacy of greater occipital nerve (GON) blockade at chronic migraine (CM) treatment.

MATERIALS AND METHODS

Patients with CM were randomly divided into two groups of 42. GON blockade was administered four times (once per week) with saline in group A or bupivacaine in group B. After 4 weeks of treatment, blinding was removed; in group A, GON blockade was achieved using bupivacaine, while group B continued to receive bupivacaine, and blockade was administered once per month, then followed for 2 months. Primary endpoint was the difference in number of headache days, duration of headache, and pain scores.

RESULTS

Seventy-two of 84 patients completed the study. After 1 month of treatment, number of headache days had decreased from 16.9 ± 5.7 to 13.2 ± 6.7 in group A (P = 0.035) and from 18.1 ± 5.3 to 8.8 ± 4.8 in group B (P < 0.001), (P = 0.004, between groups); duration of headache (hour) had decreased from 24.2 ± 13.7 to 21.2 ± 13.4 in group A (P = 0.223) and from 25.9 ± 16.3 to 19.3 ± 11.5 in group B (P < 0.001), (P = 0.767, between groups). VAS score decreased from 8.1 ± 0.9 to 6.7 ± 1.6 in group A (P = 0.002) and from 8.4 ± 1.5 to 5.3 ± 2.1 in group B (P < 0.001), (P = 0.004, between groups). After blinding was removed (in 2nd and 3rd month), group A exhibited similar results like group B in 3rd month.

CONCLUSIONS

Our results suggest that GON blockade with bupivacaine was superior to placebo and was found to be effective, safe, and cost-effective for the treatment of CM. According to our knowledge, this is the first randomized, multicentre, double-blind, and placebo-controlled study in the literature in this field of work.

Preventive effect of greater occipital nerve block on severity and frequency of migraine headache

BACKGROUND

Despite a favorable clinical experience, little evidence exists for the efficacy of greater occipital nerve block (GONB) in migraine treatment. Considering such a premise, we wished to evaluate the therapeutic efficacy of GONB in patients affected by migraine headaches.

METHODS

A randomized double-blinded controlled trial was conducted on 48 patients suffering from migraine headaches. A syringe containing 1.0 mL of lidocaine 2%, 0.5 mL of either saline (control group, N = 24) or triamcinolone 0.5 mL (intervention group, N = 24) was prepared for each patient. Patients were assessed prior to the injection, and also 2 weeks, 1 month, and 2 months thereafter for severity and frequency of pain, times to use analgesics and any appeared side effects.

RESULTS

No significant differences were revealed in pain severity, pain frequency, and analgesics use between the two groups at the four study time points including at baseline, and 2, 4, and 8 weeks after the intervention. However, in both groups, the indices of pain severity, pain frequency, and analgesics use were significantly reduced at the three time points after the intervention compared with before the intervention.

CONCLUSION

GONB with triamcinolone in combination with lidocaine or normal saline with lidocaine results in reducing pain severity and frequency as well as use of analgesics up to two months after the intervention, however any difference attributed to the drug regimens by assessing of the trend of pain characteristics changes.

Treatment of migraine: update on new therapies

PURPOSE OF REVIEW

This review provides a comprehensive selection of the latest clinical trial results in antimigraine treatment.

RECENT FINDINGS

The oral calcitonine gene-related peptide antagonist telcagepant is efficacious in acute treatment. Compared to triptans, its efficacy is almost comparable but its tolerance is superior. The same is true for the 5HT-1F agonist lasmiditan, another agent devoid of vascular effects. Triptans, as other drugs, are more efficient if taken early but nonsteroidal anti-inflammatory drugs and analgesics remain useful for acute treatment, according to several meta-analyses. Single-pulse transcranial magnetic stimulation during the aura rendered more patients pain-free (39%) than sham stimulation (22%) in one study. Topiramate could be effective for migrainous vertigo, but it did not prevent transformation to chronic migraine in patients with high attack frequency. Onabotulinumtoxin A was effective for chronic migraine and well tolerated, but the therapeutic gain over placebo was modest; the clinical profile of responders remains to be determined before widespread use. Occipital nerve stimulation was effective in intractable chronic migraine with 39% of responders compared to 6% after sham stimulation. This and other neuromodulation techniques, such as sphenopalatine ganglion stimulation, are promising treatments for medically refractory patients but large controlled trials are necessary. One study suggests that outcome of patent foramen ovale closure in migraine might depend on anatomic and functional characteristics.

SUMMARY

Drugs with a better efficacy or side-effect profile than triptans may soon become available for acute treatment. The future may also look brighter for some of the very disabled chronic migraineurs thanks to novel drug and neuromodulation therapies.