Nerve Block for The Treatment of Headaches

1. Ade Wijaya, MD – December 2018

2.  Nerve block consists of transitory cessation of nerve impulse conduction, usually
for the purpose of pain relief
 Minimally invasive procedure
 Well accepted and tolerated, and is not often associated with serious adverse
effects
 Lidocaine & corticosteroids
Dach, F., Éckeli, Á. L., Ferreira, K. D. S., & Speciali, J. G. (2015). Nerve block for the treatment of headaches and cranial neuralgias–a practical approach. Headache: The Journal of Head and Face Pain, 55, 59-71.

3. Dach, F., Éckeli, Á. L., Ferreira, K. D. S., & Speciali, J. G. (2015). Nerve block for the treatment of headaches and cranial neuralgias–a practical approach. Headache: The Journal of Head and Face Pain, 55, 59-71.

4. Dach, F., Éckeli, Á. L., Ferreira, K. D. S., & Speciali, J. G. (2015). Nerve block for the treatment of headaches and cranial neuralgias–a practical approach. Headache: The Journal of Head and Face Pain, 55, 59-71.

5.  Lidocaine is a common local anesthetic and antiarrhythmic drug first synthesized
under the name xylocaine in 1943
 Rapid onset of action, intermediate duration and anesthetic potency, and low
toxicity
 Block the sodium channels in a frequency-dependent and voltage dependent
manner
 A major effect of lidocaine is to further decrease Na+ currents, thereby
suppressing cellular excitability
 Thus, through the blockage of Na+ channel activity, the nerve block with lidocaine
stops the nociceptive firing and the neuronal hyperexcitability in first order
neurons, reducing peripheral sensitivity
Dach, F., Éckeli, Á. L., Ferreira, K. D. S., & Speciali, J. G. (2015). Nerve block for the treatment of headaches and cranial neuralgias–a practical approach. Headache: The Journal of Head and Face Pain, 55, 59-71.

6.  Reduction of inflammation by inhibiting the synthesis or release of a number of
proinflammatory substances,some cytokines and other acute phase reagents
 A direct membrane-stabilizing effect
 Reversible inhibition of nociceptive C-fiber transmission
 Modulation of nociceptive input within the dorsal horn substantia gelatinosa
neurons
Li H, Xie W, Strong JA, Zhang JM. Systemic anti-inflammatory corticosteroid reduces mechanical pain behavior, sympathetic sprouting, and elevation of proinflammatory cytokines in a rat model of neuropathic pain.
Anesthesiology. 2007;107:469-477.
Li JY, Xie W, Strong JA, Guo QL, Zhang JM. Mechanical hypersensitivity, sympathetic sprouting, and glial activation are attenuated by local injection of corticosteroid near the lumbar ganglion in a rat model of neuropathic
pain. Reg Anesth Pain Med. 2011;36:56-62.

7.  Primary headaches
 Secondary headaches (cervicogenic, headache attributed to craniotomy)
 Cranial neuralgias (trigeminal, glossopharyngeal, occipital)
Dach, F., Éckeli, Á. L., Ferreira, K. D. S., & Speciali, J. G. (2015). Nerve block for the treatment of headaches and cranial neuralgias–a practical approach. Headache: The Journal of Head and Face Pain, 55, 59-71.

8.  Infection and malformation (eg, hemangioma) at the injection site
 Allergy to anesthetics and corticosteroids
 Anticoagulation
 Diseases that increase bleeding time (eg, idiopathic thrombocytopenic purpura)
 Arrhythmias
 Liver failure
 When the patient does not consent to this procedure
Amador E, Mackey S. Peripheral nerve blocks and continuous catheters. In: Wallace M, Staats P, eds. Pain Medicine and Management. Just the Facts. New York: McGraw-Hill; 2005:102-105.

9.  Pregnant / breastfeeding woman
 The use of corticosteroids on the face and forehead should be avoided due to
aesthetic issues
 Patients with active peptic ulcer, ulcerative colitis, active infection, hypertension,
congestive heart failure, renal disease, and psychiatric illness are more prone to
side effects.
Blumenfeld A, Ashkenazi A, Napchan U, et al. Expert consensus recommendations for the performance of peripheral nerve blocks for headaches –A narrative review. Headache. 2013;53:437-446.
Shields KG, Levy MJ, Goadsby PJ. Alopecia and cutaneous atrophy after greater occipital nerve infiltration with corticosteroid. Neurology. 2004;63:2193-2194.
Schimmer BP, Parker KL. Adrenocorticalsteroids. In: Hardman JG, Gilman AG, Limbird LE, eds. Goodman and Gilman’s The Pharmacological Basis of Therapeutics.NewYork: McGraw-Hill; 1996:1465-1481.

10.  The most common side effects are pain, ecchymosis, and hematoma at the site of
injection
 Atrophy and hyper- or hypopigmentation of the skin and hair loss
 Dizziness, nervousness, facial flushing, insomnia, and transient increased
appetite
 Muscle paralysis
 Severe adverse events, such as coma, are also possible.
Dach, F., Éckeli, Á. L., Ferreira, K. D. S., & Speciali, J. G. (2015). Nerve block for the treatment of headaches and cranial neuralgias–a practical approach. Headache: The Journal of Head and Face Pain, 55, 59-71.

11.  The nerve block can be used in primary and secondary headaches.
 In some of them this procedure is necessary for both diagnosis and treatment (eg,
cervicogenic headache and occipital neuralgia), while in others it is an adjuvant
treatment (eg, migraine).
 The block of GON with an anesthetic and corticosteroid compound has proved to
be effective in the treatment of cluster headache.