Interventional Procedures for Headaches: Acute and Preventative

CHAPTER 234 Interventional Procedures for Headaches


Acute and Preventative



Duren Michael Ready


Headaches are an almost universal condition. They are as old as humankind. Headache management evolved beyond “taking two aspirins” with the development of the ergots and migraine-specific triptan medications. Physicians frequently still encounter patients who have broken through their prophylaxis, failed acute treatments, and are in need of rescue therapies.


The introduction of sumatriptan and the subsequent development of additional triptans have proven to be a great enhancement for the acute and rescue treatment of migraine and cluster headaches. Triptans are still considered to be underused medications. However, even they have their limits. They work best when used at the onset of mild pain and are of very limited utility 24 hours after onset of the headache. Unfortunately, when we encounter many of these difficult patients, it is too late to use them.


Several of the procedures discussed here are older (greater and lesser occipital nerve blocks and sphenopalatine nerve blocks) and well established in the medical literature. However, newer techniques (botulinum toxin and paracervical intramuscular spinal blocks) are under increasing study and use.


There are multiple benefits to incorporating injection procedures into the management of headaches. They can provide some of the fastest relief (occipital nerve blocks, paracervical intramuscular spinal blocks), are the most comfortable (sphenopalatine ganglion blocks), and the most beneficial to patients with refractory headache (botulinum toxin). They are relatively simple, easy to learn, and provide a great deal of patient satisfaction.


An additional benefit to using injection procedures for acute or rescue management of headaches is to stem the use of narcotics. A recent study surveyed Canadian emergency department acute headache treatments and reported that over half of patients had their first exposure to narcotics in the emergency department as a rescue therapy. There has been a growing consensus among physicians treating headaches that narcotics should be used, if at all, only as a last resort. This is because of their almost universal tendency to sensitize the central nervous system and ultimately make the headaches refractory to treatment.


A history and physical examination are essential before initiating treatment to rule out any “red flags” for secondary headaches that are caused by treatable conditions. Usually the history will reveal a primary headache disorder that allows for a satisfactory treatment plan. But it is also important to discover potential contraindications to these procedures, such as prior cranial surgery. The physical primarily identifies secondary causes of headaches. In primary headache disorders such as migraine or tension-type headache, the physical examination is usually unrevealing (Table 234-1).


TABLE 234-1 Red Flags for Acute Secondary Headache Disorders







































Red Flag Differential Diagnosis Possible Work-up
Headache beginning after 50 years of age Temporal arteritis, mass lesion Erythrocyte sedimentation rate, neuroimaging
Sudden onset of headache Subarachnoid hemorrhage, pituitary apoplexy, hemorrhage into a mass lesion or vascular malformation, mass lesion (especially posterior mass) Neuroimaging; lumbar puncture if neuroimaging is negative*
Headaches increasing in frequency and severity Mass lesion, subdural hematoma, medication overuse Neuroimaging, drug screen
New-onset headache in a patient with risk factors for human immunodeficiency virus infection or cancer Meningitis (chronic or carcinomatous), brain abscess (including toxoplasmosis), metastasis Neuroimaging; lumbar puncture if neuroimaging is negative*
Headache with signs of systemic illness (fever, stiff neck, rash) Meningitis, encephalitis, Lyme disease, systemic infection, collagen vascular disease Neuroimaging, lumbar puncture,† serology
Focal neurologic signs or symptoms of disease (other than typical aura) Mass lesion, vascular malformation, stroke, collagen vascular disease Neuroimaging, collagen vascular disease evaluation (including anti-phospholipid antibodies)
Papilledema Mass lesion, pseudotumor cerebri, meningitis Neuroimaging, lumbar puncture†
Headache subsequent to head trauma Intracranial hemorrhage, subdural hematoma, epidural hematoma, post-traumatic headache Neuroimaging of brain, skull, and, possibly, cervical spine

* Lumbar puncture may follow a negative neuroimaging procedure if suspicion of hemorrhage, infection, or malignancy remains high.


† Suspicion of specific central nervous system infections (e.g., Lyme disease, syphilis) or intracranial hypertension (pseudotumor cerebri) warrants lumbar puncture with cerebrospinal fluid analysis and pressure measurement.


From Newman LC, Lipton RB: Emergency department evaluation of headache. Neurol Clin 16:285–303, 1998.


Most patients have sought help only after they have failed their usual prophylaxis and available acute treatments. Although pharmacologic interventions are still an option, procedural treatments for the most part are simple and safe, and they can be a beneficial asset for the treatment and prevention of many headache disorders. In this chapter, we discuss lower cervical intramuscular blocks, occipital nerve blocks, sphenopalatine ganglion blocks, and botulinum toxin injections.


Also, see Chapter 8, Peripheral Nerve Blocks and Field Blocks, Chapter 9, Oral and Facial Anesthesia, and Chapter 56, Botulinum Toxin.



Lower Cervical Intramuscular Injections


In 2006, Mellick and colleagues reported a 1-year retrospective review of lower cervical intramuscular injections in over 400 emergency department patients treated for headaches. The results were impressive: 65.1% had resolution within 15 minutes and an additional 20.4% had partial relief within 20 minutes. When patients who were not pain free 20 minutes after treatment were reinjected, additional improvement was seen in 59.5% of the patients. The study did not attempt to differentiate between headache subtypes, so the procedure can be tried with most headaches.



Anatomy


Landmarks to identify include the spinous processes of T1, C6, and C7. The injections are placed 2 to 3 cm lateral to the midline either at the level of C6 or C7, so there is some latitude as to their placement. Although there are no major arteries in the area it is always a good practice to aspirate before injections.



Indications


Although indications have not been well established, generally this procedure is beneficial for migraine, tension-type, post-traumatic, and cervicogenic headaches.



Relative and Absolute Contraindications


Secondary headache disorders are a relative contraindication (see Table 234-1).Treatment of the headache should not interfere with treatment of the underlying condition. Allergy to the local anesthetics is also a contraindication.



Equipment and Supplies



• Bupivacaine 0.5% 3 mL (1.5 mL injected bilaterally)

• Syringe with 25-gauge, image-inch needle

• Gebauer’s ethyl chloride (optional vapocoolant spray to minimize injection discomfort)


Precautions


As with all injections, sterile technique is essential. Inject slowly to minimize risk of a vasovagal reaction.



Technique


See Figure 234-1.


1 Have the patient seated with the neck flexed, chin toward chest. The forehead can rest on crossed forearms.

2 Identify the T1 spinous process by finding the superiormost rib. Walk your fingertips medially to the spinous process and move up one or two levels to the C6 or C7 level. Identify the areas for injection bilaterally, 2 to 3 cm lateral to the selected spinous process (two fingerbreadths approximates 3 cm for many people).

3 Insert the needle to the hub perpendicular to the cervical spine, toward the anterior neck.

4 Once fully inserted to the needle’s hub, aspirate, and if there is no return, inject all of the bupivacaine slowly in one spot. After all of the bupivacaine is injected, withdraw the needle and apply an adhesive strip (Band-Aid) at the site of the injection.

5 Repeat the injection on other side.

6 The injection may be repeated once in 20 to 30 minutes if the headache has not resolved.


image

image

Figure 234-1 Lower cervical intramuscular injection. A, A 25-gauge, image-inch needle attached to a 10-mL syringe filled with 3 mL of 0.5% bupivacaine is inserted up to the hub into the paraspinous muscles, 2 to 3 cm lateral to the midline at a level between the C6 and C7 spinous processes and at an angle perpendicular to the cervical spine. The bupivacaine is injected slowly to minimize patient discomfort. After 1.5 mL of the bupivacaine has been injected, the needle is withdrawn, the injection site is bandaged, and the procedure is repeated on the other side. B, Lower cervical intermuscular injection. The injections are placed perpendicular to the cervical spine, 2 to 3 cm lateral to the area between the C6 and C7 spinous processes.


It is not known whether relief is a function of resolution of muscle tension, reflex arc to the spinal trigeminal nucleus, a combination of the two, or some other mechanism of action.



Common Errors


The procedure itself is very simple and does not lend itself to many errors.



Complications


Adverse events are uncommon and limited, but have been reported as muscle soreness at injection sites, transient weakness of posterior neck muscles, and vasovagal reactions.



Postprocedure Management


Typically, placement of a bandage is all that is required after an injection; however, if any complications develop they should be managed before patient discharge.



CPT/Billing Code








20552 Injection(s); single or multiple trigger point(s), one or two muscles

This is a common code for cervicalgia, which is frequently associated with headaches.



Greater and Lesser Occipital Nerve Blocks


The greater and lesser occipital nerve blocks are additional beneficial procedures that are well established and relatively simple to learn. In a study by Ashkenazi and Young (2005), 89.5% of patients with episodic or transformed migraines responded to greater occipital nerve blocks (GONB). The GONB has been used as an acute and a preventative treatment for migraine, cluster, and tension-type headaches. This block is a popular treatment for individuals who need quick relief without sedation, although it is slightly more uncomfortable than the lower cervical intramuscular injection. Patients who describe their headaches as “exploding” typically find the greatest relief. The recent discovery of transcranial sensory nerves connecting the scalp and the dura offers an interesting possibility for a mechanism of action, although the exact mechanism has yet to be defined.



Anatomy


The greater occipital nerve (GON) rises out of the dorsal primary rami of cervical spinal nerves 2 and 3. It provides cutaneous sensation to the medial posterior portion of the scalp. The lesser occipital nerve (LON) represents the ventral branches of C2 and C3. These origins suggest a possible mechanism of action: a reflex signal transmitted to the spinal trigeminal nucleus through the C2 nerve.


The GON and LON emerge from underneath the muscles at the level of the nuchal ridge. The GON lies about 2 to 3 cm lateral to the greater occipital protuberance and adjacent to the greater occipital artery. Attempt to palpate the greater occipital artery to approximate the GON. The GON is frequently tender to palpation during acute headaches.



Indications


The GONB is indicated for prevention and treatment of primary headache conditions and other cephalgias in the back of the neck. In earlier clinical trials steroids have not been shown to significantly enhance the effectiveness of an ONB, with the noted exception of cluster headaches. When corticosteroids are used, their frequency should be moderated to typically no greater than one every 3 months, with a continuing assessment of individual risks and benefits. If no steroids are used, the risks and benefits of repeated injections of local anesthetic should guide decisions about frequency.



Relative and Absolute Contraindications


Occipital nerve block is relatively contraindicated in the presence of a bony defect. Patients with a prior occipital or mastoid craniotomy should be injected only by a skilled clinician familiar with the patient to avoid any risk of spinal anesthesia. Caution should also be used in patients with impaired glucose tolerance or diabetes because the steroids may worsen hyperglycemia. In these instances the blocks may be performed with local anesthetic alone.



Equipment and Supplies


Amounts listed here are for unilateral injections. They will need to be doubled for bilateral injections.


• Steroid: typically no more than 1 mL per side.
• Intermediate-acting, moderate-potency: triamcinolone acetonide 20 to 40 mg (Kenalog 40 mg/mL).

• Long-acting, high-potency: dexamethasone 4 mg (Decadron 4 mg/mL)

• Local anesthetic: 0.5% bupivacaine 3 mL.

• Local anesthetic: 1% lidocaine with or without epinephrine (optional). If lidocaine is used, the patient may report onset of the anesthetic effects of the block while it is still being administered, thereby making the block more tolerable.

• 10-mL syringe with a 25-gauge needle

• The desired quantity of steroid is drawn up into the syringe using a 20-gauge needle and sterile technique, followed by the desired quantities of the bupivacaine or lidocaine. The total volume should be 3 to 4 mL of solution for a unilateral block and 6 to 8 mL of solution for a bilateral block.


Precautions


Always confirm a patient’s allergies to medications before any procedure.



Procedure


Many techniques have been reported in the literature, but this is no comparison study of the merits of one injection technique over another. It appears best to block the GON and LON by inserting the needle between them and advancing it toward the respective nerves (always aspirating before injection), thereby providing a block that is complete over the superior nuchal ridge. Other clinicians have reported success with blocking the GON and LON using two separate injections.



Greater and Lesser Occipital Nerve Block with One Injection Site


See Figure 234-2.


1 Have the patient lean forward with the chin flexed forward toward the chest and the head resting on the forearms.

2 Identify the superior nuchal ridge from the medial greater occipital protuberance to the lateral mastoid process. Attempt to palpate the greater occipital artery.

3 Introduce the needle between the approximated GON and LON and advance to the skull, withdraw the needle slightly, and administer a small bolus of the solution.

4 Advance the needle medially toward the GON (staying above the nuchal line), aspirate, and inject approximately 2 mL of solution.

5 Withdraw the needle and redirect toward the mastoid process, aspirate, and inject the remaining solution.

6 Repeat the procedure on contralateral side if the headache is bilateral.


image

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Figure 234-2 A, Occipital nerve block. An imaginary curvilinear line is drawn over the superior nuchal line between the greater occipital protuberance and the mastoid process. The line is then divided into thirds. The medial division represents the approximate position of the greater occipital nerve (GON). The lateral division represents the position of the lesser occipital nerve (LON). Injections may be placed over the GON and LON (circles [i.e., nerve sites]) or the injection maybe placed between the nerves at the superior nuchal line and directed toward the GON and LON. B, Occipital nerve block. An imaginary curvilinear line is drawn over the superior nuchal line between then greater occipital protuberance and the mastoid process. The line is then divided into thirds. The medial division represents the approximate position of the GON. The lateral division represents the position of the LON. Injections may be placed over the GON and LON (their approximate position [i.e., nerve sites] as labeled on the imaginary curvilinear line), or the injections may be placed between the nerves (marked by the Xs) at the superior nuchal line and directed medially toward the GON and then redirected laterally toward the LON.


(B, From Cousins MJ, Carr DB, Horlocker TT, Bridenbough P [eds]: Cousins and Bridenbough’s Neural Blockade in Clinical Anesthesia and Pain, 4th ed. Philadelphia, Lippincott Williams & Wilkins, 2008, p 421.)

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May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Interventional Procedures for Headaches: Acute and Preventative

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