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Background and Aims The trigeminal nerve, supplying craniofacial structures, is involved in facial pain pathologies. Pain of trigeminal origin is also projected to the territory of the greater occipital nerve. These patterns of pain referral reflect a broad overlap of cervical and trigeminal afferents. Convergent peripheral nerves integrate occipitocervical and trigeminal Ad-fiber and C-fiber inputs. Afferent-driven presynaptic inhibition can finetune nociceptive information flow. An intervention at this level could theoretically improve pain scores.

Methods A 68 year old male patient presented with a bilateral trigeminal nevralgia refractory to treatment. He has a personal history of multiple sclerosis and trigeminal nevralgia – since 2011, for which he is presently medicated with carbamazepine 400mg bid, gabapentin 400mg qid, transdermic fentanyl 50mcg every 3 days, morphine 10mg SOS, paracetamol 1000mg bid, sertraline 50mg id, alprazolam 0,5mg id and diazepam 10mg id. He refers dysphagia and choking. Sublingual fentanyl 133 mcg and sphenopalatine ganglion block had poor results. The next step would be surgical radioablation.

Results In the next consultation, the patient presented with a 8/10 pain and we performed an ultrasound guided bilateral occipital nerve block with ropivacaine 2mg/ml and metilprednisolone 40mg, 1.5ml on side and the results were immediate, with reported pain scores of 0/10 and were maintained for two weeks.

Conclusions Trigeminal nevralgia can be challenging to manage, leading to severe decrease of quality of life. Occipitocervical inputs can modulate pain responses originated from the trigeminal nerve. Presynaptic inhibition could explain improved pain scores in our patient and could be promising therapeutic targets in chronic pain settings.