Neck Injections for Headaches

Larry Mellick, MD, MS, FAAP, FACEP
Professor of Emergency Medicine and Pediatrics
Medical College of Georgia
Augusta

Pearl: Sometimes giving patients a temporary pain in the neck can take away their headaches.

Presentation: The first patient presented for evaluation and treatment of a headache that developed following a spinal tap performed several days previously. He was diagnosed as having a headache related to his recent spinal tap and he initially was treated with intravenous fluids and 500 mg of caffeine (IV). These interventions were unsuccessful, and the patient was subsequently treated with bilateral lower cervical injections with 0.5% bupivacaine (1.5 mL) injected in the paraspinous muscles at about the C-6 or C-7 level. His headache went from a numerical descriptor scale of 9/10 to 0/10 in about five minutes.

The second patient presented complaining of two types of headaches. One was a chronic headache condition and the other of more recent onset was described as sharp, severe shooting pains from the right occipital area. Palpation over the occipital area reproduced the pain. This patient's clinical presentation was consistent with the diagnosis of occipital neuralgia. The injection of bupivacaine 0.5% and methylprednisolone sodium succinate (Solu-Medrol) 20 mg with a 25-gauge needle (1.5 cm) into the occipital scalp brought immediate relief of the headache pain. Several 3- to 4-centimeter "ribbons" of the anesthesia steroid mixture were placed subcutaneously and intramuscularly at the base of the skull. (Figure 1)

Discussion: For the treatment of most headaches, intravenous prochlorperazine (Compazine) with diphenhydramine (to counteract the common side effect of akathisia)1 is the most effective headache treatment,2,3,4 but a bilateral lower cervical injection with bupivacaine is a useful therapeutic adjunct.5,6,7 (Figure 2) This modality also appears to provide some relief to patients with orofacial pain.8 While the mechanism is unknown, the therapeutic response would suggest that the sensitized trigeminocervical complex is calmed.9,10,11,12 It has been well established that the cervical nerves have central connections to the brainstem. The trigeminal nerve afferents also converge on the brainstem at the trigeminocervical complex, as do other structures with profound antinociceptive effects, such as the periaqueductal grey or PAG.13,14

Occipital neuralgia is clinically defined by the International Headache Society (IHS) as "a paroxysmal jabbing pain in the distribution of the greater or lesser occipital nerves or of the third occipital nerve, sometimes accompanied by diminished sensation or dysaesthesia in the affected area. It is commonly associated with tenderness over the nerve concerned." Diagnostic criteria include:15

  • paroxysmal stabbing pain, with or without persistent aching between paroxysms, in the distribution(s) of the greater, lesser, and/or third occipital nerves;
  • tenderness over the affected nerve;
  • pain that is eased temporarily by local anaesthetic block of the nerve.

This patient fit these criteria and responded nicely to the locally applied anesthesia and methylprednisolone sodium succinate. (Figure 1)

The dorsal primary rami of the C2, C3, and C4 cervical roots provide sensation to the posterior neck. The greater, third, and lesser occipital nerves are potential sources of pain. The pathophysiology of occipital neuralgia is not certain, but entrapment of the occipital nerves by surrounding muscles is one consideration. Other etiologies that can cause irritation of the nerves include trauma, downward and forward head positioning for long periods of time, osteoarthritis, tumors, or localized inflammation or infection.16

Besides the local injection of anesthetic and steroids, the application of either moist heat or cold may benefit some patients. Treatment of neuropathic pain frequently includes anticonvulsants such as gabapentin or carbamazepine, and these medications sometimes are used to treat this condition. Tricyclic antidepressants also commonly are used for chronic pain management. When cervical strain appears to be the inciting mechanism, the application of a cervical collar may be considered.

References:

  1. Drotts DL, Vinson DR. Prochlorperazine induces akathisia in emergency patients. Ann Emerg Med 1999;34:469-475.
  2. Coppola M, Yealy DM, Leibold RA. Randomized, placebo-controlled evaluation of prochlorperazine versus metoclopramide for emergency department treatment of migraine headache. Ann Emerg Med 1995;26:541-546.
  3. Jones J, Sklar D, Dougherty J, et al. Randomized double-blind trial of intravenous prochlorperazine for the treatment of acute headache. JAMA 1989;261:1174-1176.
  4. Ginder S, Oatman B, Pollack M. A prospective study of IV magnesium and IV prochlorperazine in the treatment of headaches. J Emerg Med 2000;18:311-315.
  5. Mellick LB, McIlrath ST, Mellick GA. Treatment of headaches in the ED with lower cervical intramuscular bupivacaine injections: A 1-year retrospective review of 417 patients. Headache 2006;46:1441-1449.
  6. Mellick GA, Mellick LB. Lower cervical injections for headache relief. Letter. Headache 2001;41:992-994.
  7. Mellick GA, Mellick LB. Regional head and face pain relief following lower cervical intramuscular anesthetic injection. Headache 2003;43:1111-1113.
  8. Mellick LB, Mellick GA. Treatment of acute orofacial pain with lower cervical intramuscular bupivacaine injections: A 1-year retrospective review of 114 patients. J Orofac Pain 2008;22:57-64.
  9. Abrahams VC, Anstee G, Richmond FJ, et al. Neck muscle and trigeminal input to the upper cervical cord and lower medulla of the cat. Can J Physiol Pharmacol 1979;57:642-651.
  10. Piovesan EJ, Kowacs PA, Tatsui CE, et al. Referred pain after painful stimulation of the greater occipital nerve in humans: Evidence of convergence of cervical afferences on trigeminal nuclei. Cephalalgia 2001;21:107-109.
  11. Bartsch T, Goadsby PJ. Stimulation of the greater occipital nerve induces increased central excitability of dural afferent input. Brain 2002;125:1496-1509.
  12. Bartsch T, Goadsby PJ. Increased responses in trigeminocervical nociceptive neurons to cervical input after stimulation of the dura mater. Brain 2003;126:1801-1813.
  13. Bartsch T, Goadsby PJ. The trigeminocervical complex and migraine: Current concepts and synthesis. Curr Pain Headache Rep 2003;7:371-376.
  14. Mason P. Deconstructing endogenous pain modulations. J Neurophysiol 2005;94:1659-1663.
  15. IHS Classification ICHD II. International Headache Society. http://ihs-classification.org/en/02_klassifikation/04_teil3/13.08.00_facialpain.html
  16. NINDS Occipital Neuralgia Information Page. National Institute of Neurological Disorders and Stroke. http://www.ninds.nih.gov/disorders/occipitalneuralgia/occipitalneuralgia.htm

Online Resource:

  1. http://ihs-classification.org/en/02_klassifikation/

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