Neurol Sci (2010) 31 (Suppl 1):S179S180

DOI 10.1007/s10072-010-0320-7

ORAL COMMUNICATION

Greater occipital nerve block in chronic migraine

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Maria Gabriella Saracco W. Valfre`

M. Cavallini M. Aguggia

Springer-Verlag 2010

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measure was the change in mean headache severity from

before injection to 20 min after in the two groups. Secondary outcome measures were the change in mean neck
pain, photophobia and phonofobia severity from before
injection to 20 min after in the two groups. Patients documented headache and severity of associated symptoms for
4 weeks after injection. Changes in symptom severity were
compared between the two groups. Thirty-seven patients
were included. Twenty minutes after injection, mean
headache severity decreased by 3.2 points in group A
(p \ 0.01) and by 3.1 points in group B (p \ 0.01). Mean
neck pain severity decreased by 1.5 points in group A
(p \ 0.01) and by 1.7 points in group B (p \ 0.01). Mean
duration of being headache-free was 2.7 3.8 days in
group A and 1.0 1.1 days in group B (p = 0.67). None of
the outcome measures differed significantly between the
two groups. Both treatments were full tolerated. In our
study, adding triamcinolone to local anaesthetic when
perfoming GONB and TPIs was not associated with
improved outcome in the sample of patients with TM. In
both groups, the procedure resulted in significant and rapid
relief of headache, neck pain, photophobia and phonofobia.

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Abstract Headache syndromes often involve occipital

and neck symptoms suggesting a functional connectivity
between nociceptive trigeminal and cervical afferents.
Several studies have suggested that pain relief in migraine
and other types of headache can be achieved by local
injections of steroids, local anaesthetics or a mixture of
both in the area of greater occipital nerve (GON). Usually
greater occipital nerve block (GONB) is performed by
using local anaesthetics alone or with steroid. The rationale
of performing a GONB for the treatment of chronic
headache states is on the anatomical connections between
trigeminal and upper cervical sensory fibres at the level of
the trigeminal nucleus caudalis. However, the reason for
the improvement after GONB in primary headache is
unknown. The objective of this study is to determine
whether adding triamcinolone to local anaesthetics
increased the efficacy of GONB and trigger point injections
(TPIs) for chronic migraine (TM). Patients with TM were
randomized to receive GONB and TPIs using lidocaine 2%
and bupivacaine 0.5% ? either saline or triamcinolone 40
mg. Particularly, a 10-ml syringe containing 4.5 ml of
lidocaine 2%, 4.5 ml of bupivacaine 0.5% and 1 ml of
either saline (group A) or triamcinolone 40 mg/ml (group
B) was prepared for each patients. Patients were given
bilateral GONB and TPIs in the cervical paraspinal and
trapezius muscles bilaterally. 2 ml were injected into each
GON at the medial third of the distance between the
occipital protuberance and the mastoid process. In addition,
0.5 ml was injected into each of the 12 trigger points. The
total injected volume was 10 ml. The primary outcome
M. G. Saracco (&)
W. Valfre`
M. Cavallini
M. Aguggia
Neurological Department, ASL AT-Asti,
Ospedale Cardinal Massaia, Via Conte Verde 125, Asti, Italy
e-mail: saraccomg@asl.at.it; sgabriella@aol.it

Keywords Greater occipital nerve block

Chronic migraine
Local anaesthetic
Triamcinolone

Background
Migraine is a common neurological disorder that has a
wide variety of subtypes, many comorbidities, and a variable prognosis [1]. Migraine that undergoes progression
clinically evolves to high-frequency episodic migraine or
chronic migraine. Functional changes may accompany
migraine progression, including the development of

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Neurol Sci (2010) 31 (Suppl 1):S179S180

A disturbance in the region of the head can provoke pain

in the distribution of the trigeminal and upper cervical
nerves due to a convergence of the afferent fibres of the
three superior cervical roots on the neurones of the trigeminal nerve nucleus [11], so the analgesic action of
GONB is a process most likely initiated by a diffuse
inhibitory process.

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Conclusion
In conclusion, neurophysiological and clinical data suggests a functional connectivity between the sensory
occipital segments and the trigeminal nociceptive system in
humans. GON block for migraine, and in particular in
unresponsive chronic migraine patients, should be in this
way considered an effective management tool.

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Conflict of interest statement The authors declare that they have

no conflict of interest related to the publication of this article.

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allodynia, and changes in the periacqueductal gray matter.

These findings support the hypothesis that migraine is not
just an episodic disorder but a chronic disorder with episodic manifestations [2]. Moreover, headache syndromes
often involve occipital and neck symptoms, suggesting a
functional connectivity between nociceptive trigeminal and
cervical afferents. The most likely mechanism for this
observation is referred pain originating from structures
in the neck and projecting to facial areas and vice versa at
the level of second-order neurons in the brainstem, which
receive convergent input from both trigeminal and cervical
territories [3]. Several studies have suggested that pain
relief in migraine, cervicogenic headache and cluster
headache can be achieved by local injections of steroids,
local anaesthetics, or a mixture of both in the area of
greater occipital nerve (GON), offering a toll for the
management of these form [4, 5]. The GON is composed of
sensory fibres that originate predominantly at the C2 level.
Its cutaneous distribution covers the posterior part of the
head up to the vertex. Usually greater occipital nerve block
(GONB) is performed by using local anaesthetics alone or
with steroid and bilateral GON, trigger-points in the cervical paraspinal and trapezius muscles are treated. The
rationale of performing a GONB for the treatment of
chronic headache states on the anatomical connections
between trigeminal and upper cervical sensory fibres at the
level of the trigeminal nucleus caudalis [6, 7]. However,
the reason for the improvement of clinical symptoms after
occipital nerve blockade in primary headache patients is
unknown. Several hypotheses have been suggested,
including inhibition of central-pain processing mechanisms
at the brainstem level, a systemic steroid effect and placebo
effects.
Migraine patients, especially when affected by chronic
and aura subtype forms, often have increased skin sensitivity to non-noxious stimuli and GONB may play a role in
cutaneous allodynia in migraine. In fact, allodynia is
thought to be caused by the headache and the activation of
nociceptors with the development of central sensitization in
subjects with an altered regulation of the central nociceptive pathway [8]. The persistence of pain sensation seems
to be able to induce central sensitization in the caudal
nucleus of the trigeminal nerve by lowering the neuronal
pain threshold [9].
GONB alleviate head pain by altering the nociceptive
input to the trigeminal-cervical complex. Based on findings
from experimental studies, electrical stimulation and local
anaesthetic blocks of the GON has been shown to have a
facilitatory effect on dural nociceptive stimulation suggesting the subsequent induction of central sensitization on
the second-order neurone receiving cervical and trigeminal
input [10].

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