Nerve Blocks for Headaches & Migraine

A recent study looking at the current practice patterns in the use of nerve blocks and trigger point injections for pediatric headache disorders has found that nerve blocks are commonly used, despite limited evidence.

“This study demonstrated similar rates of use of nerve blocks and trigger point injections among respondents compared with the adult practice pattern survey from 2010,” Christina L. Szperka, MD, of the department of neurology, University of Pennsylvania, and colleagues wrote in Headache. “Similar to that study, there was wide variability in the indications for injection, sites and frequency injected, and medications used. Given the demonstrated variability, and the interest among the group in further research, additional placebo-controlled studies should be done.”

Peripheral nerve blocks are used to modulate pain signals coming from nerves using local anesthetic medications. Nerve blocks are often used in adults and children to treat headaches, but there are few data looking at practice patterns of their use in a pediatric setting.

Szperka and colleagues created a survey and sent it to 82 members of the Pediatric and Adolescent Section of the American Headache Society. The survey asked about current practices and use of nerve blocks, as well as opinions on gaps in evidence for the use of nerve blocks in a pediatric setting.

The researchers received 41 complete, five incomplete, and three duplicate responses. Seventy-eight percent of respondents said their primary specialty was child neurology and 51% were certified in headache medicine. According to the researchers, “having a primary specialty of adult or child neurology and UCNS certification in headache medicine were associated with increased likelihood of using peripheral nerve blocks.”

The majority of respondents reported performed nerve blocks themselves (63%) and an additional 17% referred patients to another provider for nerve blocks. Among those respondents who performed the nerve blocks themselves, there was significant variability in the implementation of this treatment for headache. The most common indications for nerve block were: chronic migraine with status migrainosus (82%), occipital neuralgia (79%), status migrainosus (73%), chronic migraine without flare (70%), post-traumatic headache (70%), and new daily persistent headache (67%).

The respondents injected in a variety of sites including the greater occipital nerve (100%), lesser occipital nerve (69%), supraorbital (50%), trigger point injections (46%), auriculotemporal (42%), and supratrochlear (34%).

“There was also variability regarding injection location-respondents inject anywhere from 1 to 10 sites around the head in a single procedure session,” the researchers wrote. “This variability closely paralleled the results of the adult practice pattern survey from 2010.”

All of the respondents used local anesthetic, and about one-half of respondents also added corticosteroids (46%). No respondents used epinephrine, fentanyl, or clonidine.

When asked what they consider the minimum clinically meaningful response for nerve blocks, the most common answer for chronic migraine was a 50% or greater reduction in headache frequency at 4 weeks (41%) and a 30% or greater reduction in headache frequency at 4 weeks (24%). For status migrainosus the most common answer was a 50% of greater reduction in severity (41%).

Reference: Szperka CL, et al. Patterns of use of peripheral nerve blocks and trigger point injections for pediatric headache: results of a survey of the American Headache Society Pediatric and Adolescent Section. Headache. Epub 2016 Oct 12.