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Anderson CC, Iser CR, Hirte IL, Boddu S, Girardo ME, VanderPluym JH, Starling AJ. Sequential administration of peripheral nerve blocks and onabotulinumtoxinA for the treatment of chronic migraine and other headache disorders-A retrospective tolerability and safety study. Headache 2024. [PMID: 38700250 DOI: 10.1111/head.14725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 02/22/2024] [Accepted: 02/22/2024] [Indexed: 05/05/2024]
Abstract
OBJECTIVE To determine the tolerability and safety of concurrent peripheral nerve blocks and onabotulinumtoxinA treatment during a single outpatient clinic procedure visit. BACKGROUND Procedural interventions are available for the treatment of headache disorders. OnabotulinumtoxinA and peripheral nerve blocks are used as alternatives or in addition to oral therapies to reduce the frequency and intensity of migraine attacks. There is currently a lack of safety data focusing on the sequential administration of local anesthetic via peripheral nerve blocks and onabotulinumtoxinA during a single clinical encounter for the treatment of headache. The primary aim of the study was to determine the safety and tolerability of concurrent peripheral nerve blockade and onabotulinumtoxinA injections during a single outpatient clinic procedure visit. We hypothesized that the dual intervention would be safe and well tolerated by patients with chronic migraine and other headache disorders. METHODS A retrospective chart review was performed using clinical data from patients seen by multiple providers over a 16-month timeframe at one outpatient headache clinic. Patients were identified by procedure codes and those receiving peripheral nerve block(s) and onabotulinumtoxinA injections during a single encounter within the study period were eligible for inclusion. Inclusion criteria were (1) patients 18 years and older who were (2) receiving both peripheral nerve blocks and onabotulinumtoxinA injections for the treatment of chronic migraine. Patients were excluded if they were under age 18, received their procedure outside of the clinic (emergency room, inpatient ward), or were receiving sphenopalatine ganglion blocks. Age- and sex-matched patients who received one procedure, either peripheral nerve blocks or onabotulinumtoxinA, were used for control. The primary outcome of this safety study was the number of adverse events that occurred in the dual intervention group compared to the single intervention control arms. Information regarding adverse events was gathered via retrospective chart review. If an adverse event was recorded, it was then graded by the reviewer utilizing the Common Terminology Criteria for Adverse Events ranging from Grade 1 Mild Event to Grade 5 Death. Additionally, it was noted whether the adverse event led to treatment discontinuation. RESULTS In total, 375 patients were considered eligible for inclusion in the study. After age and sex matching of controls, 131 patients receiving dual intervention were able to be compared to 131 patients receiving onabotulinumtoxinA alone and 104 patients receiving dual intervention were able to be compared to 104 patients receiving peripheral nerve block(s) alone. The primary endpoint analysis showed no significant difference in total adverse events between dual intervention compared to nerve blocks alone or onabotulinumtoxinA alone. The number of adverse events that led to treatment discontinuation approached but did not reach statistical significance for those receiving dual intervention versus onabotulinumtoxinA alone in the number of adverse events that led to treatment termination (4.6%, 6/131 vs. 0.8%, 1/131, p = 0.065); however, the number of patients who discontinued therapy was not significantly different between those groups (2.3%, 3/131 vs. 0.8%, 1/131; p = 0.314; odds ratio 0.3 [0-3.2]; p = 0.338). CONCLUSIONS In this retrospective chart review, there was no significant difference in adverse events or therapy discontinuation between patients receiving sequential peripheral nerve block(s) and onabotulinumtoxinA injections versus those receiving either peripheral nerve block(s) or onabotulinumtoxinA injections alone. As a result, we concluded that the combination procedure is likely safe and well tolerated in routine clinical practice.
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Affiliation(s)
| | - Courtney R Iser
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Ingrid L Hirte
- Mayo Clinic Alix School of Medicine-Arizona, Mayo Clinic, Phoenix, Arizona, USA
| | - Sayi Boddu
- Mayo Clinic Alix School of Medicine-Arizona, Mayo Clinic, Phoenix, Arizona, USA
| | - Marlene E Girardo
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, Arizona, USA
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Robblee J, Hakim SM, Reynolds JM, Monteith TS, Zhang N, Barad M. Nonspecific oral medications versus anti-calcitonin gene-related peptide monoclonal antibodies for migraine: A systematic review and meta-analysis of randomized controlled trials. Headache 2024; 64:547-572. [PMID: 38634515 DOI: 10.1111/head.14693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 02/22/2024] [Accepted: 02/22/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVE To compare calcitonin gene-related peptide monoclonal antibodies (CGRP mAbs) versus nonspecific oral migraine preventives (NOEPs). BACKGROUND Insurers mandate step therapy with NOEPs before approving CGRP mAbs. METHODS Databases were searched for class I or II randomized controlled trials (RCTs) comparing CGRP mAbs or NOEPs versus placebo for migraine prevention in adults. The primary outcome measure was monthly migraine days (MMD) or moderate to severe headache days. RESULTS Twelve RCTs for CGRP mAbs, 5 RCTs for topiramate, and 3 RCTs for divalproex were included in the meta-analysis. There was high certainty that CGRP mAbs are more effective than placebo, with weighted mean difference (WMD; 95% confidence interval) of -1.64 (-1.99 to -1.28) MMD, which is compatible with small effect size (Cohen's d -0.25 [-0.34 to -0.16]). Certainty of evidence that topiramate or divalproex is more effective than placebo was very low and low, respectively (WMD -1.45 [-1.52 to -1.38] and -1.65 [-2.30 to -1.00], respectively; Cohen's d -1.25 [-2.47 to -0.03] and -0.48 [-0.67 to -0.29], respectively). Trial sequential analysis showed that information size was adequate and that CGRP mAbs had clear benefit versus placebo. Network meta-analysis showed no statistically significant difference between CGRP mAbs and topiramate (WMD -0.19 [-0.56 to 0.17]) or divalproex (0.01 [-0.73 to 0.75]). No significant difference was seen between topiramate or divalproex (0.21 [-0.45 to 0.86]). CONCLUSIONS There is high certainty that CGRP mAbs are more effective than placebo, but the effect size is small. When feasible, CGRP mAbs may be prescribed as first-line preventives; topiramate or divalproex could be as effective but are less well tolerated. The findings of this study support the recently published 2024 position of the American Headache Society on the use of CGRP mAbs as the first-line treatment.
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Affiliation(s)
- Jennifer Robblee
- Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Sameh M Hakim
- Department of Anesthesiology, Intensive Care, and Pain Management, Ain Shams University Faculty of Medicine, Cairo, Egypt
| | - John M Reynolds
- The Louis Calder Memorial Library, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Teshamae S Monteith
- Division of Headache, Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Niushen Zhang
- Department of Neurology & Neurological Sciences, Stanford Health Care, Stanford, California, USA
| | - Meredith Barad
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Health Care, Stanford, California, USA
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Cortel-LeBlanc MA, Orr SL, Dunn M, James D, Cortel-LeBlanc A. Managing and Preventing Migraine in the Emergency Department: A Review. Ann Emerg Med 2023; 82:732-751. [PMID: 37436346 DOI: 10.1016/j.annemergmed.2023.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 07/13/2023]
Abstract
Migraine is a leading cause of disability worldwide, and acute migraine attacks are a common reason for patients to seek care in the emergency department (ED). There have been recent advancements in the care of patients with migraine, specifically emerging evidence for nerve blocks and new pharmacological classes of medications like gepants and ditans. This article serves as a comprehensive review of migraine in the ED, including diagnosis and management of acute complications of migraine (eg, status migrainosus, migrainous infarct, persistent aura without infarction, and aura-triggered seizure) and use of evidence-based migraine-specific treatments in the ED. It highlights the role of migraine preventive medications and provides a framework for emergency physicians to prescribe them to eligible patients. Finally, it evaluates the evidence for nerve blocks in the treatment of migraine and introduces the possible role of gepants and ditans in the care of patients with migraine in the ED.
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Affiliation(s)
- Miguel A Cortel-LeBlanc
- Department of Emergency Medicine, Queensway Carleton Hospital, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Institut du Savoir Montfort, Ottawa, ON, Canada; 360 Concussion Care, Ottawa, ON, Canada.
| | - Serena L Orr
- Departments of Pediatrics, Community Health Sciences, and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Maeghan Dunn
- Department of Emergency Medicine, Queensway Carleton Hospital, Ottawa, ON, Canada
| | - Daniel James
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Emergency Medicine, The Ottawa Hospital, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Achelle Cortel-LeBlanc
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Institut du Savoir Montfort, Ottawa, ON, Canada; 360 Concussion Care, Ottawa, ON, Canada; Division of Neurology, Department of Medicine, Queensway Carleton Hospital, Ottawa, ON, Canada
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Turan SA, Aydın Ş, Gözükara MG, Çabalar M. Ultrasound-Guided Combined Greater Occipital Nerve Block at the C2 Level with Trapezius Trigger Point Injection and Supraorbital-Supratrochlear Nerve Block: More Effective on Allodynia and Disability in Chronic Migraine. Ann Indian Acad Neurol 2023; 26:943-951. [PMID: 38229643 PMCID: PMC10789420 DOI: 10.4103/aian.aian_677_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 08/29/2023] [Accepted: 09/11/2023] [Indexed: 01/18/2024] Open
Abstract
Background Chronic migraine (CM) patients with cutaneous allodynia (CA) show a poor response to treatment. Long-term studies have yet to be conducted to demonstrate the efficacy of blocks on CA. This study evaluated the improvement in allodynia and disability in CM treated with ultrasound (US)-guided blocks. Methods In this prospective, non-randomized comparative study, 60 CM patients with CA were evaluated for the clinical effectiveness of the therapy using the numeric rating scale (NRS), headache impact test-6 (HIT-6), brush allodynia test, and allodynia symptom checklist (ASC-12). At the first visit, tenderness in the nerve or trapezius muscle was confirmed in the intervention group. US-guided greater occipital nerve block (GONB), GONB, and trapezius muscle injection (TPI), or GONB, TPI, and peripheral trigeminal nerve block (PTNB), respectively, were performed four times once a week for a month. Initial and third-month assessments were performed. Results The ASC-12 scores decreased in the GONB+TPI+PTNB and GONB groups more than the GONB+TPI group (mean rank, respectively, 26.86, 27.40, 38.39; P = 0.018). The decrease in HIT-6 scores was greater in the GONB+TPI+PTNB group than in the GONB group (mean rank, respectively, 21.98, 39.95, P < 0.017) in the first month. In the third month, the GONB+TPI+PTNB group scored HIT-6 significantly lower than GONB and GONB+TPI (mean rank: 18.84, 38.73, 35.61; P < 0.001). Conclusions GONB+TPI+PTNB was more successful in alleviating allodynia and disability.
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Affiliation(s)
- Suna Aşkın Turan
- Department of Pain, Basaksehir Cam and Sakura City Hospital, University of Health Sciences, İstanbul
| | - Şenay Aydın
- Department of Neurology, Yedikule Chest Disease and Surgery Training and Research Hospital, University of Health Sciences, Istanbul
| | - Melih G. Gözükara
- Public Health Department, School of Medicine, Ankara Yıldırım Beyazıt University, Ankara, Turkiye
| | - Murat Çabalar
- Department of Neurology, Basaksehir Cam and Sakura City Hospital, University of Health Sciences, İstanbul
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Towne BV, Girgiss CB, Schuster NM. Use of spinal cord stimulation in treatment of intractable headache diseases. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:S6-S10. [PMID: 37833045 DOI: 10.1093/pm/pnad090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/17/2023] [Accepted: 06/27/2023] [Indexed: 10/15/2023]
Abstract
Headache diseases remain one of the leading causes of disability in the world. With the development of neuromodulation strategies, high cervical spinal cord stimulation (hcSCS) targeting the trigeminocervical complex has been deployed to treat refractory headache diseases. In this article, we review the proposed mechanism behind hcSCS stimulation, and the various studies that have been described for the successful use of this treatment strategy in patients with chronic migraine, cluster headache, and other trigeminal autonomic cephalalgias.
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Affiliation(s)
- Brooke V Towne
- Department of Anesthesiology, University of California San Diego Health, San Diego, CA 92037, United States
| | - Carol B Girgiss
- School of Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Nathaniel M Schuster
- Department of Anesthesiology, University of California San Diego Health, San Diego, CA 92037, United States
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Castillo-Álvarez F, Hernando de la Bárcena I, Marzo-Sola ME. Greater occipital nerve block in the treatment of headaches. Review of evidence. Med Clin (Barc) 2023:S0025-7753(23)00177-X. [PMID: 37100680 DOI: 10.1016/j.medcli.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/01/2023] [Accepted: 04/04/2023] [Indexed: 04/28/2023]
Abstract
INTRODUCTION Peripheral nerve blocks have been a common treatment for multiple headaches. By far, the greater occipital nerve block is the most used and with the stronger body of evidence in routine clinical practice. METHODS We searched Pubmed Meta-Analysis/Systematic Review, in the last 10 years. Of these results, meta-analyses, and in the absence of these systematic reviews, assessing Greater Occipital Nerve Block in headache has been selected for review. RESULTS We identified 95 studies in Pubmed, 13 that met the inclusion criteria. CONCLUSION Greater occipital block is an effective and safe technique, easy to perform and which has shown its usefulness in migraine, cluster headache, cervicogenic headache and Post-dural puncture headache. However, more studies are needed to clarify its long-term efficacy, its place in clinical treatment, the possible difference between different anaesthetics, the most convenient dosage and the role of concomitant use of corticosteroids.
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Stern JI, Chiang C, Kissoon NR, Robertson CE. Narrative review of peripheral nerve blocks for the management of headache. Headache 2022; 62:1077-1092. [DOI: 10.1111/head.14385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 06/21/2022] [Accepted: 07/18/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Jennifer I. Stern
- Headache Division, Department of Neurology Mayo Clinic Rochester Minnesota USA
| | - Chia‐Chun Chiang
- Headache Division, Department of Neurology Mayo Clinic Rochester Minnesota USA
| | - Narayan R. Kissoon
- Headache Division, Department of Neurology Mayo Clinic Rochester Minnesota USA
- Division of Pain Medicine, Department of Anesthesiology Mayo Clinic Rochester Minnesota USA
| | - Carrie E. Robertson
- Headache Division, Department of Neurology Mayo Clinic Rochester Minnesota USA
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Outpatient Approach to Resistant and Refractory Migraine in Children and Adolescents: a Narrative Review. Curr Neurol Neurosci Rep 2022; 22:611-624. [PMID: 36018499 DOI: 10.1007/s11910-022-01224-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Migraine is one of the top reasons for consulting a pediatric neurologist. Although the majority of children and adolescents who receive evidence-based first-line interventions for migraine will improve substantially, a subset of patients develop resistant or refractory migraine. RECENT FINDINGS In this review, we summarize the level of evidence for a variety of acute and preventive treatment options to consider in children and adolescents with resistant or refractory migraine. We describe the level of evidence for interventional procedures (onabotulinumtoxinA injections, greater occipital and other nerve blocks), neuromodulation (single-pulse transcranial magnetic stimulation, external trigeminal nerve stimulation, remote electrical neuromodulation, and non-invasive vagal nerve stimulation), calcitonin gene-related peptide (CGRP) pathway antagonists (anti-CGRP monoclonal antibodies and gepants), psychological therapies, and manual therapies (acupuncture, craniosacral therapy, massage and physical therapy, and spinal manipulation).
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Raieli V, Reina F, D’Agnano D, Nocera GM, Capizzi M, Marchese F, Sciruicchio V. The Pediatric Trochlear Migraine: Diagnostic and Therapeutic Implications. J Clin Med 2022; 11:2826. [PMID: 35628950 PMCID: PMC9142906 DOI: 10.3390/jcm11102826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 05/02/2022] [Accepted: 05/16/2022] [Indexed: 11/16/2022] Open
Abstract
Trochlear Migraine has been recently described as the concurrence of strictly unilateral migraine and ipsilateral trochleodynia with relief of migraine after successful treatment of trochleodynia. This disorder has been interpreted as "cluster-tic syndrome" or "seizure-triggered migraine". Trochlear Migraine is unrecognized and rarely described in childhood. The aim of this study is to review the few cases of Trochlear Migraine reported in the literature in addition to the cases observed in our clinical experience. In particular, our cases showed recurrent attacks of severe and pulsating headache associated with nausea, vomiting, phonophobia, photophobia, and strict trochlear localization of pain. They often presented with alternating side attacks. Therefore, we suggest that the term "Trochlear Migraine" should be reserved for clinical migraine attacks strictly localized in the trochlear region, and we assume that the excessive increase in descriptions of new primary headache syndromes, according to the International Classification of Headache Disorders, can be probably be ascribed to the common physiopathological mechanisms characterizing these forms of migraine.
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Affiliation(s)
- Vincenzo Raieli
- Child Neuropsychiatry Unit ISMEP, ARNAS Civico, 90134 Palermo, Italy;
| | - Federica Reina
- Child Neuropsychiatry School, University of Palermo, 90128 Palermo, Italy; (F.R.); (G.M.N.); (M.C.)
| | - Daniela D’Agnano
- Children Epilepsy and EEG Center, PO, San Paolo ASL, 70132 Bari, Italy; (D.D.); (V.S.)
| | - Giovanna Martina Nocera
- Child Neuropsychiatry School, University of Palermo, 90128 Palermo, Italy; (F.R.); (G.M.N.); (M.C.)
| | - Mariarita Capizzi
- Child Neuropsychiatry School, University of Palermo, 90128 Palermo, Italy; (F.R.); (G.M.N.); (M.C.)
| | | | - Vittorio Sciruicchio
- Children Epilepsy and EEG Center, PO, San Paolo ASL, 70132 Bari, Italy; (D.D.); (V.S.)
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Kissoon NR, O'Brien TG, Bendel MA, Eldrige JS, Hagedorn JM, Mauck WD, Moeschler SM, Olatoye OO, Pittelkow TP, Watson JC, Pingree MJ. Comparative Effectiveness of Landmark-guided Greater Occipital Nerve (GON) Block at the Superior Nuchal Line Versus Ultrasound-guided GON Block at the Level of C2: A Randomized Clinical Trial (RCT). Clin J Pain 2022; 38:271-278. [PMID: 35132029 DOI: 10.1097/ajp.0000000000001023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 01/11/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The purpose of this single center, prospective randomized controlled trial was to compare clinical outcomes between an ultrasound-guided greater occipital nerve block (GONB) at the C2 vertebral level versus landmark-based GONB at the superior nuchal line. METHODS Patients with occipital neuralgia or cervicogenic headache were randomized to receive either a landmark-based GONB with sham ultrasound at the superior nuchal line or ultrasound-guided GONB at the C2 vertebral level with blinding of patients and data analysis investigators. Clinical outcomes were assessed at 30 minutes, 2 weeks, and 4 weeks postinjection. RESULTS Thirty-two patients were recruited with 16 participants in each group. Despite randomization, the ultrasound-guided GONB group reported higher numeric rating scale (NRS) scores at baseline. Those in the ultrasound-guided GONB group had a significant decrease in NRS from baseline compared with the landmark-based GONB group at 30 minutes (change of NRS of 4.0 vs. 2.0) and 4-week time points (change of NRS of 2.5 vs. -0.5). Both groups were found to have significant decreases in Headache Impact Test-6. The ultrasound-guided GONB had significant improvements in NRS, severe headache days, and analgesic use at 4 weeks when compared with baseline. No serious adverse events occurred in either group. CONCLUSIONS Ultrasound-guided GONBs may provide superior pain reduction at 4 weeks when compared with landmark-based GONBs for patients with occipital neuralgia or cervicogenic headache.
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Affiliation(s)
- Narayan R Kissoon
- Division of Pain Medicine, Department of Anesthesiology
- Department of Neurology, Mayo Clinic, Rochester, MN
| | | | | | - Jason S Eldrige
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Jacksonville, FL
| | | | | | | | | | | | - James C Watson
- Division of Pain Medicine, Department of Anesthesiology
- Department of Neurology, Mayo Clinic, Rochester, MN
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Hakim SM. Parasternal plane block: a new technique added to our armamentarium, or a new issue added to our debates? Minerva Anestesiol 2021; 87:1284-1286. [PMID: 34874134 DOI: 10.23736/s0375-9393.21.16222-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Sameh M Hakim
- Department of Anesthesiology, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt -
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