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Comparison of two ultrasound-guided techniques for greater occipital nerve injections in chronic migraine: a double-blind, randomized, controlled trial
  1. David Flamer1,
  2. Husni Alakkad2,
  3. Neilesh Soneji3,
  4. Paul Tumber3,4,
  5. Philip Peng4,
  6. Jamal Kara3,
  7. Yasmine Hoydonckx3 and
  8. Anuj Bhatia4
  1. 1 Anesthesia and Pain Management, University of Toronto, Toronto, Ontario, Canada
  2. 2 Department of Anesthesia and Pain Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
  3. 3 Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
  4. 4 Anesthesia, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
  1. Correspondence to Anuj Bhatia, FIPP CIPS EDRA, Toronto Western Hospital, McL 2-405, Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada; anuj.bhatia{at}uhn.ca

Abstract

Background and objectives Two ultrasound (US)-guided techniques for greater occipital nerve (GON) block have been described for the management of headache disorders: a “proximal or central” technique targeting the GON at the level of the second cervical vertebra and a “distal or peripheral” technique targeting the GON at the level of the superior nuchal line. In this multicenter, prospective, randomized control trial, we compared accuracy, effectiveness, and safety of these two techniques in patients with chronic migraines (CMs).

Methods Forty patients with refractory CMs were randomized to receive either a proximal or distal US-guided GON block with bupivacaine and methylprednisolone acetate. The primary outcome was the difference in Numerical Rating Score (NRS) for headache intensity at 1 month. Secondary outcomes were effectiveness, performance, and safety-related. Effectiveness-related outcomes included NRS for headache intensity, number of headache days per week, patient satisfaction, quality of life, assessment of sleep quality, and sleep interruption. Performance-related outcomes included procedure time, accuracy of block, and patient discomfort. Safety-related outcomes included an assessment for adverse effects.

Results NRS pain scores were significantly reduced at 24 hours and at 1 week postprocedure in both cohorts and at 1 and 3 months in the proximal group as compared with the baseline. There was no significant difference in NRS pain scores between the two cohorts at any of the follow-up time points. There was a significant reduction in number of headache days per week at 1 month in both groups, and a significant improvement in sleep interruption at 1 week in both groups. There were no significant adverse effects.

Conclusions This study was designed to compare two different US-guided approaches for blocking the GON. Our results demonstrate that both distal and proximal techniques can provide a short-term improvement in headache intensity, reduction in number of headache days per week, and an improvement in sleep interruption. The proximal GON technique may confer more sustained analgesic benefit compared with the distal approach in patients with CM headaches.

Trial registration number NCT02031822.

  • greater occipital nerve
  • injection
  • ultrasound
  • headache
  • chronic migraine
  • pain
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Footnotes

  • Correction notice This article has been corrected since it published Online First. The corresponding author details have been amended.

  • Contributors DF: conduct of the study, drafting the article, data analysis and interpretation, critical revision of the article. HA: conception and design of the work, conduct of the study. NS: conduct of the study, critical revision of the article. PT: conduct of the study, critical revision of the article. PP: conception and design of the work, conduct of the study, critical revision of the article. JK: conduct of the study, data collection and analysis. YH: conduct of the study, critical revision of the article. AB: ​conception and design of the work, conduct of the study, data analysis and interpretation, critical revision of the article, final approval of the submitted work.

  • Funding Internal funding from Departments of Anesthesia and Pain Medicine, University Health Network – Toronto Western Hospital and Mount Sinai Hospital.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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